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Relation  of  Operating  Room  and  Adjoining  Rooms. 


THE 

OPERATING   ROOM 

AND  THE 

PATIENT 

A   MANUAL   OF  PRE-    AND  POST-OPERATIVE    TREATMENT 


BY 

RUSSELL  S.  FOWLER,  M.  D. 

CHIEF  SURGEON  FIRST  DIVISION  GERMAN  HOSPITAL  ;  SUR- 
GEON METHODIST  EPISCOPAL  HOSPITAL  ;  CONSULTING 
SURGEON      HEBREW      OUPHAN      ASYLUM,    BROOKLYN,    N.    Y. 


THIRD    EDITION 
REWRITTEN  AND    ENLARGET) 


PHILADELPHIA  AND    LONDON 

W.    B.    SAUNDERS    COMPANY 
1913 


Copyright     1906,   by   W.    B.    Saunders    Company.       Revised,   reprinted,   and   recopyrighted 

February,  1907.      Reprinted   March,   1910.     Revised,  entirely  reset,  reprinted,  and 

recopyrighted  March,   1913. 


Copyright,  1913,  by  W.  B.  Saunders  Company. 


Cow    \ 


'VT 


NTED     IN      AMERICA 

PRESS       OF 
SAUNDERS       COMPAr 
P  H  I  t_  A  D  E  I- P  M  I  A 


OO 


PREFACE  TO  THE  THIRD  EDITION 

I  WISH  to  acknowledge  my  indebtedness  to  Dr.  James  W. 
Ingalls  for  the  paragraphs  upon  enucleation  of  the  eyeball;  to 
Dr.  William  W.  Laing  for  his  collaboration  in  the  paragraphs 
on  vaccine  therapy;  to  Dr.  Carl  Fulda  for  translations  from  the 
German;  to  Dr.  W.  C.  Woolsey  for  collaboration  in  the  chapter 
on  Anesthesia;  to  Dr.  Robert  L.  Moorhead  for  collaboration  in 
the  paragraphs  on  Tracheotomy;  to  Dr.  Paul  O.  Humpstone  for 
contributing  the  paragraphs  upon  Obstetric  Operations;  to  Mr. 
Francis  A.  Deck  for  his  admirable  illustrations,  many  of  which 
are  from  "A  Treatise  on  Surgery,"  by  George  Ryerson  Fowler; 
to  the  W,  B.  Saunders  Company  for  their  cooperation,  and  to  all 
those  faithful  friends  who  make  life  worth  living  and  work  a 
pleasure. 

Whether  a  single  operation  is  contemplated  or  a  series, 
whether  in  a  hospital  or  in  a  private  house,  the  precautions  to 
be  observed  are  the  same.  It  has  been  my  purpose  to  simplify 
the  technic  as  much  as  is  compatible  with  careful  work  and  to 
present  the  subject  in  a  terse,  yet  I  hope,  readable  manner. 
Simplification  and  standardization  are  the  keynotes  of  the  hour; 
hence  many  of  the  early  methods  have  been  discarded  for  others 
which  experience  has  proven  efficient  and  better  because  simpler. 

Roughly,  the  underlying  principles  of  successful  surgical  treat- 
ment may  be  summarized  as  follows:  Careful  anesthesia,  exact 
hemostasis,  asepsis,  rest  of  the  injured  part,  use  of  the  rest  of 
the  body,  feeding  advanced  to  normal  as  fast  as  the  anesthetic 
weakened  stomach  can  care  for  it,  and  the  following  of  the 
general  rules  of  hygiene.  R.  S.  F. 

Brooklyn,  N.  Y.,  March,  1913. 


13 


CONTENTS 

CHAPTER  I 

Page 

The  Operating  Room 17 

CHAPTER  II 

Preparation  of  Instruments  and  Supplies 30 

CHAPTER  III 
Bandaging 63 

CHAPTER  IV 
Anesthesia 135 

CHAPTER  V 
Pre-operative  Preparation  and  the  Primary  Dressing   ,    .    .    .    163 

CHAPTER  VI 

General  Considerations  in  the    After-treatment 190 

CHAPTER  VII 
Care  of  the  Wound 225 

CHAPTER  VIII 
Hemorrhage : 257 

CHAPTER  IX 
Complications  of  Wound  Infections 271 

CHAPTER  X 

Complications   the    Result   of   Antiseptics;   Complications   the 

Result  of  Pressure;  Circulatory  Complications  .    .    .   282 

CHAPTER  XI 

Operations  Upon  Special  Tissues 303 

15 


16  COXTEXTS 

CHAPTER  XII  ^^'^= 

Operatioxs  Upox  Special  Tissues  (coxtixced) 328 

CHAPTER  XIII 
Operatioxs  Upox  the  Head 351 

CHAPTER  XIV 
Operatioxs  Upox  the  Xeck 393 

CHAPTER  XV 
Operatioxs  Upox   the    Thor.^x 424 

CHAPTER  XVI 

Operatioxs  Upox  the  Abdomex 442 

CHAPTER  XVII 
Operatioxs  Upox  the  Rectum  axd  Axus 489 

CHAPTER  XVIII 
Extraperitoxeal  Operatioxs  Upox  the  Kidxets  axd  Ureters   .    .   497 

CHAPTER  XIX 
Operatioxs  Upox  the  Bladder 508 

CHAPTER  XX 
Operatioxs  Upox  the  Male  Gexitals 522 

CHAPTER  XXI 
Operatioxs  Upox  the  Female  Gexitalia 527 

CHAPTER  XXII 
Operatioxs  Upox  the  Vertebral  Columx      452 

CHAPTER  XXIII 
Lists  of  Ixstrumexts  axd  Dressixgs  Commoxly  Employed      .    .   553 
IXDEX 5S3 


THE  OPERATING  ROOM 

AND 

THE  PATIENT 


CHAPTER  I. 
THE  OPERATING  ROOM. 

General  considerations.  Operating  room  furniture.  Disinfection  of  the 
operating  room.  Preparation  of  the  operating  table;  sinks;  scrub-up  tray; 
hand  basins,  pitchers,  pus  basins  and  dressing  pails;  glassware.  Arrange- 
ment during  operation.  Arrangement  of  the  instrument  and  sponge  table. 
Arrangement  of  the  portable  instrument  stand.  General  operating  room 
rules.  Personnel  of  the  operating  room.  Operating  room  costumes.  Oper- 
ating room  nurse.  Senior  operating  room  nurse.  First  junior  operating 
room  nurse.  Second  junior  operating  room  nurse.  Supply  room  nurse. 
Anesthetic  nurse.  Operating  room  orderly.  Operations  in  private  houses. 
Operating  furniture  in  jarivate  houses. 

General  Considerations. — ^The  ideal  hospital  operating  room 
(Fig.  1)  should  be  on  the  top  floor  with  ample  floor  space  and 
moderately  high  ceiling  with  a  large  double  air-tight,  central 
skylight.  The  east  side  of  the  room  should  have  large  windows. 
The  floor,  walls,  and  ceiling  should  be  of  waterproof  construction 
with  rounded  corners.  The  floor  should  incline  slightly  to  a 
central  drain.  Heating  should  be  by  hot  water.  Lighting 
should  be  by  electricity  on  two  circuits,  the  fixtures  being  a 
parallelogram  with  a  central  cluster.  Gas  should  also  be  in- 
stalled in  case  of  accident  to  the  electricity.  An  ideal  relation 
of  the  operating  room  to  the  adjoining  rooms  is  shown  in  the 
frontispiece. 

The  operating  room  furniture  consists  of  two  or  more  operating 
tables  (Fig.  2)  a  long  curved  table  for  instruments,  sponges, 
2  17 


18 


OPERATING    ROOM    AND    THE    PATIENT 


ligatures  and  dressings,  an  adjustable  instrument  table,  three 
stools,  a  portable  irrigation  stand,  a  stand  for  the  large  bichlorid 
hand  bath,  six  basins  and  stands  for  solutions,  two  screens,  a 
wheeled  table  for  the  scrubbing  outfit,  four  sinks  with  hot  and 
cold  water  taps,  a  waste  sink,  pails  and  receptacles  for  soiled 
gauze,  gowns,  etc.,  a  portable  parabolic  light,  a  stand  or  inclosure 
for  visitors. 


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tJO 


Disinfection  of  the  Operating  Room. — ^The  walls  and  ceiling  of 
the  operating  room  should  be  washed  down  with  a  hose  using 
hot  water  at  least  twice  a  month.  Furniture  is  scrubbed  with 
soap  and  water  and  wiped  off  with  bichlorid  (1 :  1000)  or  carbolic 
(1 :  20) ,  and  the  floor  flushed  and  mopped  dry  after  every  septic 


OPERATING    ROOM  19 

operation  and  after  every  series  of  clean  operations.  The  room 
is  dusted  daily  and  should  always  be  ready  for  use.  The  air 
of  the  room  should  be  moist.  All  windows  are  kept  closed  and 
drafts  avoided.  In  summer  those  windows  which  are  to  be 
kept  open  in  rooms  adjoining  the  operating  room  should  be 
provided  with  screens.  The  temperature  of  the  room  should 
be  between  75°  and  80°  F.     Ventilators  are  covered  with  non- 


Fig.  2. — Author's  operating  table. 
A,  wheel  to  incline  table;  B,  wheel  to  elevate  table;  C,  wheel  to  control 
kidney  elevator;  D,  showing  entire  table  partially  elevated;  E,  foot  brake; 
F,    instrument  stand;  G,  hand-rest;  H,   Bierhoff  stirrups;  I,  foot- rest;  J, 
shoulder-rest;  K,  kidney  support;  L,  various  forms  of  head  supports. 


absorbent  cotton  filters.  Once  each  month  the  operating  room 
is  disinfected  by  the  formalin  process.  This  method  is  also 
used  after  cases  of  streptococcic  infections. 

Preparation  of  Operating  Table. — On  the  table  are  placed  the 
Trendelenburg  shoulder  crutches,  with  small  rubber  pads  at- 
tached to  protect  the  patient  from  undue  pressure,  a  long  rubber 
cushion  with  linen  slip  cover,  a  small  rubber  pillow  with  linen 


20  OPERATING    ROOM    AXD    THE    PATIENT 

cover.  The  lithotomy  posts  and  stirrups,  the  attachment  for 
operations  upon  the  hand  and  forearm  and.  the  various  head 
attachments  should  be  near  at  hand. 

Preparation  of  the  Sinks. — Nail  scissors,  nail  files,  wire  nail 
brushes,  a  jar  containing  hand  brushes,  a  jar  of  green  soap,  a 
bottle  of  alcohol,  and  a  bottle  of  hand  lotion  are  placed  on  a  small 
table  or  shelf  near  the  sinks.  Bottles  have  bichlorid  towels 
pinned  around  them  or  are  covered  with  bottle  bags  with,  draw- 
strings to  fasten  around  the  neck  of  the  bottle  to  prevent 
slipping. 

The  scrub-up  tray  is  placed  on  a  small  wheeled  table.  It 
contains  a  large  flask  of  sterile  water  with  aseptic  cotton  plug, 
a  large  flask  of  acid-bichlorid,  liquid  green  soap,  tincture  of  iodin, 
Woelfler's  solution,  alcohol,  ether,  and  a  razor;  it  is  convenient 
to  keep  safety-pins,  bandages,  adhesive  plaster  and  scissors  on 
this  tray. 

Hand  basins,  pitchers,  pus  basins  and  dressing  pails  are  scrubbed 
with  soap  and  water  and  sterilized  by  boiling  for  ten  minutes 
in  a  utensil  sterilizer.  Nickel  and  brass  work  are  cleansed  daily 
with  "bon  ami"  and  polished  with  a  dry  chamois. 

Glassware  is  cleansed  by  scrubbing  with  soap  and  water, 
rinsed,  then  sterilized  by  boiling  for  ten  minutes  in  the  utensil 
sterilizer,  allowed  to  cool,  and  polished  with  gauze  wet  with 
alcohol. 

Arrangement  during  Operation  (Fig.  3). — ^The  table  (1)  is  so 
placed  as  to  afford  the  best  possible  light  on  the  field  of  operation; 
the  anesthetist  (A)  seated  at  the  head,  the  operator  (B)  to  one 
side  of  the  field  of  operation;  his  adjimct  (C)  opposite;  the  house 
surgeon  (D)  to  the  right  of  the  operator;  the  senior  assistant  (E) 
to  the  left  of  the  adj  unct ;  the  main  instrument  table  (2)  behind 
the  adjunct;  the  operating  room  nurse  (G)  at  the  instrument 
table;  the  adjustable  instrument  table  (3)  convenient  to  the 
operator;  the  senior  operating  room  nurse  (F)  near  the  adjusta- 
ble table;  near  the  operator  a  basin  (4)  for  hand  solution;  also 
one  at  the  adjunct's  left;  to  either  side  of  the  table  is  a  pail  for 
soiled  sponges  (5) ;  on  one  side  of  the  room  the  sinks  (6)  with 
soap,  brushes,  etc.,  nearby  the  stand  containing  the  bichlorid 
bath   (7);  the  visitor's  stand  or  inclosure  (8)  is  so  placed  as  to 


OPERATING    ROOM 


21 


be  readily  accessible  from  the  operating  room  entrance;  the  large 
receptacles  (9)  for  soiled  dressings,  gowns,  etc.,  are  at  the  farther 
side  of  the  operating  room. 


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Fig.  3. — Arrangement  of  apparatus  and  personnel  during  operation. 

Arrangement  of  the  Instrument  and  Sponge  Table  (Fig.  4). — 
A  certain  method  should  be  instituted  and  held  to  in  the  arrange- 
ment of  instruments,  dressings,  suture  material,  gowns,  etc. 
Gowns  and  protectors  may  be  placed  upon  the  lower  shelf  of  the 


22 


OPERATIXG    ROOM    AXD    THE    PATIENT 


table.  Extra  instruments  and  instruments  not  for  use  in  the 
operation  being  performed  are  kept  on  the  second  shelf,  while 
clamps,  knives,  anatomical  forceps,  scissors,  needles,  ligature 
material,  sponges,  compresses  and  those  things  which  are  apt  to 
be  called  for  frequently  are  kept  in  their  appropriate  places  on 
the  upper  shelf.  If  the  same  place  is  always  selected  for  the 
various  articles  time  will  be  saved.     Gloves  and  rubber  goods 


Fig.  4. — Arrangement  of  instrument  and  sponge  table. 

are  kept  in  the  hand  basins  attached  to  the  table,  while  at  the 
end  of,  on  the  rest  provided  for  them,  are  the  trays  from  the 
instrument  sterilizer. 

Arrangement  of  the  Portable  Instrument  Stand  (Fig.  5). — 
This  is  first  covered  with  a  loose  sterile  bag,  the  bag  extending 
well  down  over  the  shaft  of  the  stand.  On  the  shelf  sterile 
towels  are  then  placed.  The  shelf  of  the  stand  is  raised  or 
lowered  so  that  it  is  within  easy  reach  of  the  operator.  It  may 
be  placed  over  a  part  of  the  patient.  In  abdominal  operations 
and  in  operations  upon  the  neck  the  shelf  is  usually  placed  over 
the  thighs  of  the  patient.  A  regular  arrangement  of  the  instru- 
ments and  sponges  on  tliis  table  tends  to  rapidity.  Scissors, 
knives,  anatomical  forceps,  retractors,  hemostats,  etc.,  should 
have  their  respective  places  and  when  not  in  use  at  the  operation 
at  hand  should  be  returned  to  their  places.  The  nurse  assisting 
at  the  operation  rinses  blood  stained  instruments  and  replaces 
them. 


OPERATING    ROOM 


23 


General  Operating  Room  Rules. — ^There  must  be  no  confusion. 
Each  person  should  be  thoroughly  acquainted  not  only  with  his 
or  her  duties,  but  also  with  the  duties  of  others  employed  in  the 
operating  room.  There  must  be  no  unnecessary  talking.  Each 
movement  should  be  executed  quickly  and  noiselessly  and  with- 


Arransenicnt  of  portable  instrument  stand. 


>^ 


out  coming  in  contact  with  other  persons.     Per- 
sons having  infection  of  the  air  passages  necessi- 
.:5:^^H    tating  coughing  or  sneezing  are  not  allowed  in  the 
room. 

Personnel  of  the  Operating  Room. — ^The  operat- 
ing room  staff  consists  of  a  permanent  operating 
room  nurse,  a  senior  operating  room  nurse,  two  junior  operating 
room  nurses,  and  an  operating  room  orderly.  The  senior  and 
junior  nurses  serve  in  each  position  for  at  least  one  month. 

The  operating  staff  consists  of  the  operator,  his  adjunct,  the 
house  surgeon,  the  senior  assistant,  and  the  anesthetist.  The 
resident  pathologist  attends  operations  in  which  cultures  or 
frozen  sections  are  desired. 

Operating  Room  Costumes. — ^Nurses  w^ear  over  their  regular 
nurse's  costume  (sleeves  and  cuffs  detached)  a  plain  linen  gown 
with  long  sleeves  (Fig.  6).  These  gowns  fasten  in  the  back, 
are  snug  fitting,  and  of  sufficient  length  to  entirely  cover  the 
dress.  A  mask  is  worn  which  covers  the  nose  and  mouth.  A 
cap  is  so  arranged  as  to  entirely  cover  and  confine  the  hair.  The 
operating  room  nurse  and  senior  nurse  wear  rubber  gloves, 
Hubber-heeled  shoes  are  worn  to  prevent  slipping. 

The  anesthetist  is  provided  with  a  long-sleeved  gown  with 


24 


OPEEATIXG    ROOM    AXD    THE    PATIENT 


two  breast  pockets.  He  wears  a  mask  and  cap.  The  operating 
room  orderly  wears  a  long-sleeved  gown  and  cap  and  mask. 
Operator's  and  assistant's  gowns  (Fig.  7)  are  long-sleeved. 
Visitors  are  provided  with  freshly  laundered,  long-sleeved, 
loosely  fitting  linen  gowns.     Each  gown  is  rolled  up  in  a  compact 


Fig.  6. — Xurse's  costume. 


Fig.  7. — Assistant's  costume. 


package  and  is  not  unrolled  until  needed.  They  are  put  on  be- 
fore entering  the  operating  room.  The  number  of  visitors  is 
limited  to  the  capacity  of  the  visitor's  stand. 

Operating  Room  Nurse. — The  operating  room  nurse  is  respon- 


OPERATING    ROOM  25 

sible  for  the  care  of  the  operating  room  and  the  adjoining  rooms. 
She  prepares  all  instruments,  dressings,  ligatures,  sutures  and 
appliances  for  operations  and  those  used  in  the  hospital.  She 
keeps  a  record  of  dressings  and  appliances  issued  to  the  different 
wards  of  the  hospital,  and  prepares  a  monthly  report.  She 
stands  at  the  main  instrument  table  during  operations  and  passes 
such  instruments,  etc.,  as  the  surgeon  may  require  to  the  senior 
nurse.  She  touches  no  instrument  or  article  which  has  once  left 
her  hands  until  it  has  passed  through  the  sterilizer.  She  must  always 
be  sterile.  She  should  endeavor  to  anticipate  the  surgeon's 
needs.  She  watches  closely  the  nurses  who  assist  her  in  the 
operating  room  and  instructs  them  in  the  proper  performance 
of  their  duties.  She  allows  no  instrument,  apparatus,  or  dressing 
to  leave  the  operating  room  without  a  written  requisition.  She 
sees  that  messages  are  delivered  to  the  person  for  whom  intended. 
She  sends  all  specimens  for  examination  to  the  pathological 
laboratory,  propei'ly  labeled  with  the  name  of  the  patient,  the 
date  and  the  hospital  number. 

Senior  Operating  Room  Nurse. — ^The  senior  operating  room 
nurse  has  four  weeks  prior  experience  as  first  junior.  Under 
direction  of  the  operating  room  nurse  she  has  charge  of  sterili- 
zation and  preparation  of  material  used  in  the  operating  room 
and  also  that  sent  to  the  wards.  She  lays  out  the  towels,  pro- 
tectors, caps,  masks,  rubber  aprons,  gowns,  etc.,  necessary  for 
the  operations. 

During  operations  her  post  is  at  the  adjustable  instrument 
table.  She  passes  all  sponges,  towels,  and  protectors,  antici- 
pating the  needs  of  the  operator,  and  is  responsible  for  the  correct 
counting  of  the  sponges.  She  disinfects  and  changes  her  gloves 
after  each  operation. 

After  operations  she  cleans  instruments  and  returns  them  to 
their  places,  washes  out  blood-stained  gauze,  gowns,  etc.  She 
sees  that  the  surgeon's  dressing  room  is  provided  with  sterilized 
gowns  for  visitors  and  that  the  surgeon's  operating  clothes  are 
properly  prepared. 

The  first  junior  operating  room  nurse  is  responsible  for  the 
cleaning  of  the  operating  and  adjoining  rooms.  The  rooms  are 
dusted  each  night  before  she  goes  off  duty.     She  assists  the  senior 


26  OPERATING    ROOM    AND    THE    PATIENT 

nurse  in  the  preparation  of  material.  Before  going  off  duty, 
she  sees  that  the  operating  room,  instrument  room  and  anesthetic 
room  are  in  order,  that  the  sinks  and  basins  are  clean,  that  the 
soap,  brushes,  etc.,  are  in  their  respective  places. 

On  operating  days  she  arranges  the  operating  room  furniture, 
prepares  the  basins,  solutions,  and  the  anesthetic  room.  She 
assists  in  placing  the  patient  in  the  required  position.  The 
blankets  are  smoothly  arranged  so  as  to  completely  expose  the 
parts  to  be  operated  on,  but  no  portion  of  the  body  is  to  be  left 
unnecessarily  uncovered.  She  assists  in  preparing  the  field 
of  operation,  bringing  soap  and  water,  ether,  acid-bichlorid, 
or  iodin  as  required. 

She  fastens  the  gowns,  changes  hand  solutions  when  soiled, 
supplies  anesthetic;  picks  up  all  sponges  and  towels  which  drop 
to  the  floor;  picks  up  fallen  instruments,  cleanses  them,  and 
sterilizes  them;  collects  the  used  hand  brushes  and  sterilizes 
them;  places  freshly  sterilized  brushes  in  the  brush  jar  for  each 
case;  keeps  the  instrument  sterilizer  three-quarters  full  of  soda 
solution  and  boiling;  prepares  and  gives  hypodermic  injections; 
operates  the  thermocautery;  collects,  counts,  and  places  in  a 
pail  all  soiled  sponges  used  in  a  laparotomy,  and  reports  the  num- 
ber to  the  senior  nurse;  keeps  the  saline  solution  at  the  proper 
temperature;  takes  all  messages  coming  to  the  operating  room 
and  reports  them  to  the  operating  room  nu?"se. 

Between  operations  she  washes  the  frame  of  the  anesthetic 
mask  and  changes  the  covers.  She  brings  dry  warm  blankets 
for  the  patient  and  assists  the  ward  nurse  to  prepare  the  patient 
to  leave  the  operating  room  (dry  shirt,  stockings,  etc.);  flushes 
the  operating  room  floor  with  biclilorid  solution  after  each  septic 
case;  furnishes  fresh  hand  basins;  cleans  and  prepares  the  oper- 
ating table  for  the  next  case;  collects  soiled  gowns,  towels, 
sponges,  etc.,  and  places  them  in  their  proper  receptacles. 

On  the  completion  of  an  operation  or  series  of  operations  she 
rinses  out  the  stains  in  clothing  and  towels,  and  prepares  them 
for  the  laundry.  She  cleanses  the  rubber  aprons  with  soap  and 
water  and  wipes  them  off  with  carbolic  solution;  cleans  all  the 
operating  room  furniture,  anesthetic  table,  etc.;  sees  that  the 
solutions  are  all  in  order,  reporting  any  deficiency  to  the  operating 


OPERATING    ROOM  27 

room  nurse;  renews  all  solutions;  and  cleanses  all  glassware, 
basins,  blood-stained  gauze,  etc. 

She  watches  the  operating  room  nurse,  the  senior  nurse,  and 
the  anesthetist  and  anticipates  their  needs.  She  must  not  leave 
the  room  unless  ordered  to  do  so  by  the  operating  room  nurse. 
She  sees  that  each  visitor  is  provided  with  a  gown,  cap  and  mask. 

The  second  junior  nurse  helps  the  junior  nurse.  When  two 
operations  are  proceeding  simultaneously  she  helps  at  the  second 
operation.  At  other  times  she  is  employed  in  preparing  dressings 
and  material, 

A  supply  room  nurse  is  employed  preparing  supplies. 

The  anesthetic  nurse  accompanies  the  patient  from  the  ward 
to  the  anesthetic  room  and  remains  until  the  patient  is  taken 
to  the  operating  room.  She  marks  on  the  anesthetic  slip  her 
name,  the  name  of  the  patient,  the  variety  of  anesthetic,  the  time 
begun,  and  the  time  established;  also  the  patient's  pulse  when 
the  anesthesia  is  established.  She  watches  the  pulse  carefully, 
noting  its  quality  and  counting  it  frequently,  and  reporting  its 
rate  to  the  anesthetist.  She  assists  in  controlling  any  struggling 
of  the  patient.  She  gives  hypodermic  injections  when  ordered. 
She  must  be  familiar  with  the  use  of  the  oxygen  apparatus. 

Operating  Room  Orderly. — ^The  operating  room  orderly  re- 
mains with  the  patient  while  in  the  anesthetic  room,  assists  in 
placing  the  patient  in  position  on  the  table,  controls  any  strug- 
gling on  the  part  of  the  patient,  and  wheels  the  patient  into  the 
operating  room.  Should  the  operation  be  one  involving  the 
male  genitalia,  the  orderly  assists  in  the  preparation  of  the  field 
of  operation.  He  places  screens  around  the  operating  table.  In 
cases  in  which  he  is  not  needed  in  the  operating  room  he  remains 
in  the  anesthetic  room  and  holds  himself  in  readiness  to  receive 
orders  from  the  operating  room  nurse.  Such  messages  are  de- 
livered to  him  through  the  medium  of  the  junior  nurse.  He 
cleans  the  floors  and  fixtures  of  the  operating  and  adjoining 
rooms. 

Operations  in  Private  Houses. — ^Fewer  operations  are  done 
at  the  present  time  in  private  houses  than  formerly,  one  reason 
being  that  the  general  public  now  recognizes  the  advantage  to 
the  patient  accruing  from  operations  in  a  well  equipped  hospital 


28  OPERATING    ROOM    AXD    THE    PATIENT 

"U'here  the  surgeon  is  aided  by  assistants  and  nurses  trained  to 
his  metliods,  and  where  every  appliance  is  at  hand  to  meet  any 
emergency.  There  will,  however,  from  time  to  time  be  cases 
which  cannot  be  cared  for  in  a  hosjoital  either  through  the  very 
emergent  nature  of  the  case  or  because  the  distance  is  too  great; 
for  transportation  or  because  of  reluctance  on  the  part  of  the 
patient  to  follow  the  surgeon's  wishes.  This  latter  class  of  pa- 
tients should  have  explained  to  them  the  desirability  of  the  hos- 
pital from  an  operative  standpoint,  and  either  they  or  their 
friends  should  assume  the  additional  risk  of  oj^erating  in  the 
home. 

A  warm  well-lighted  room,  jDreferabl}^  upon  the  same  floor  as 
that  where  the  patient  lies,  is  selected.  All  preparation  should 
be  conducted  so  far  as  possible  without  disturbing  the  patient, 
as  the  knowledge  of  the  many  precautions  necessarily  taken 
might  increase  his  anxiety. 

The  preparation  of  the  room  differs  in  operations  of  conveni- 
ence and  those  of  necessity.  In  the  former  the  room  is  prepared 
several  days  in  advance.  Everything  is  removed  from  it  in- 
cluding carpet  and  hangings.  The  ceiling,  walls,  paint,  wood- 
work and  floor  are  thorouglil}'  cleansed,  proper  furniture  and 
apparatus  installed,  and  the  room  brought  as  nearly  as  possible 
to  those  conditions  which  detain  in  a  hospital. 

In  emergency  cases,  however,  harm  will  be  done  by  attempts 
at  thorough  disinfection  through  raising  dust  and  thus  circu- 
lating bacteria.  In  such  cases  the  carpet  is  covered  with  laundry 
clean  sheets,  sufficient  furniture  is  removed  to  give  room  for 
the  operating  table  and  necessary  adjuncts,  the  remaining  furni- 
ture and  mantel  shelf  being  covered  with  laundry  clean  sheets. 
Hangings  and  pictures  are  covered;  ornaments  are  removed.  In 
removing  articles  from  the  room  care  must  be  taken  not  to  raise 
any  dust.  If  an  overhead  chandelier  is  in  the  room  a  laundry 
clean  sheet  is  pinned  about  it.  If  the  operation  is  at  night  the 
lighting  portion  of  the  chandelier  is  not  covered. 

Oferating  Furniture. — Surgeons  who  are  called  more  or  less 
frequently  to  operate  in  private  houses  will  have  complete  kits 
comprising  a  portable  operating  table,  nests  of  hand  basins,  a 
portable  sterilizer,  etc.     If  such  is  not  the  case,  however,  im- 


OPERATING    ROOM  29 

provisations  must  take  their  place.  An  operating  table  is  im- 
provised by  using  a  kitchen  table  and  small  stand;  the  Trendelen- 
burg posture  is  improvised  by  inverting  a  straight-back  chair 
upon  the  table.  The  table  is  covered  with  several  blankets  and 
over  these  a  sheet  of  oil  cloth  covered  by  a  laundry  clean  sheet. 
A  moderate  sized  table  is  selected  for  an  instrument,  sponge  and 
dressing  table,  and  several  smaller  tables  for  hand  solutions, 
catgut,  etc.;  if  these  small  tables  cannot  be  procured  chairs  may 
be  utilized.  The  tables  or  chairs  are  protected  by  covering  them 
with  several  layers  of  newspaper  over  which  are  pinned  laundry 
clean  sheets.  Wooden  or  tin  pails  serve  for  waste  receptacles; 
bread  bowls  and  pitchers,  sterilized  by  boiling  in  the  clothes 
boiler,  serve  to  hold  sterile  solutions.  A  plentiful  supply  of 
cold  and  hot  sterile  water  should  be  at  hand.  Towels  and  sheets 
are  steam  sterilized  by  suspending  them  in  a  large  wash  boiler 
which  is  one-quarter  filled  with  water,  then  dried  by  placing  on 
a  rack  above  the  fire.  Instruments  are  sterilized  by  placing 
them  in  the  bottom  of  the  wash  boiler,  or  by  boiling  in  a  large 
fish  kettle.  Dressings,  gowns,  caps,  etc.,  may  be  sterilized  in  the 
same  manner  as  towels  and  sheets.  Gowns  may  be  improvised 
from  sheets,  caps  from  towels,  and  masks  from  pieces  of  gauze. 

Rarely,  however,  will  it  be  necessary  to  go  to  such  lengths. 
A  surgeon  when  called  to  a  distance  with  a  possible  operation 
before  him  will  go  equipped  for  the  emergency  so  far  as  gowns, 
caps,  masks,  sterile  dressings,  instruments,  ligature  material, 
sterile  protectors  and  towels  which  are  to  be  used  in  the  immedi- 
ate neighborhood  of  the  wound  are  concerned. 

Wherever  possible  a  gas  stove  should  be  near  the  operating 
room  so  that  in  the  event  of  the  soiling  of  any  instrument  it 
may  be  quickly  resterilized.  Douche  bags,  sterilized  by  boiling, 
serve  for  irrigation  purposes  in  an  emergency. 

The  preparation  of  the  patient  is  the  same  as  in  the  hospital. 
Nor  does  the  after-treatment  differ.  Elevation  of  the  head  of 
the  bed  can  be  secured  if  indicated  by  raising  the  head  of  the  bed 
on  a  table  or  washstand.  If  this  is  impracticable  the  sitting 
posture  may  be  improvised  by  using  an  inverted  straight-back 
chair. 


30  OPERATING  ROOM  AND  THE  PATIENT 


CHAPTER  II. 
PREPARATION  OF  INSTRUMENTS  AND  SUPPLIES. 

General  considerations.  Instruments.  Brushes.  Soap.  Nail  cleaners. 
Chlorinated  lime  and  sodium  carbonate.  Hand  lotions.  Caps.  Masks. 
Rubber  aprons.  Gowns.  Rubber  gloves.  Finger  cots.  Protectors. 
Perineal  sheets.  Anus  protectors.  Towels.  Blankets.  Screen  covers. 
Rubber  sheeting.  Covers  for  rubber  pads.  Muslin  bottle  bags.  Mushn 
hand,  foot,  arm  and  leg  bags.  Sheets,  gowns,  towels,  blankets,  etc.  Steri- 
lization. Powders.  Solutions.  Gauzes.  Gauze  drains.  Wicking  drains. 
Modified  cigarette  drain.  Mikulicz  drain.  Rubber  tissue  drains.  Umbrella 
tampon.  Cotton.  Lambs'  wool.  Sponges.  Compresses.  Graduated 
tampon.  Laparotomy  pads.  Paper  dressing.  Cleansing  of  gauze.  Waxed 
or  paraffin  paper.  Rubber  goods.  Glass  goods.  Sterilization  of  catgut. 
Kangaroo  tendon.  Silk.  Pagenstecher  thread.  Linen  thread.  Paraffin 
silk.  Silkworm  gut.  Horsehair.  Silver  \^dre.  Iron  wire.  Percentage 
table.     Thermocautery.     Sandbags.     Splints.     Adhesive  plaster. 

General  Considerations. — ^The  hospital  instrument  and  supply 
room  (Figs.  8  and  9)  should  communicate  directly  with  the 
operating  room.  It  is  a  large  room  fitted  with  numerous  drawers 
and  shelves  containing  all  the  supplies  needed  for  use  in  the  oper- 
ating room.  The  furniture  consists  of  three  enamel  chairs; 
one  long,  narrow  enamel  table  for  preparing  supplies;  bandage 
roller;  an  apparatus  for  preparing  pi aster-of -Paris  bandages; 
and  dust-proof  instrument  cases.  Glass  bowls,  mortar  and 
pestle,  glass  graduates,  mixing  rods  and  indelible  ink  for  marking 
packages  should  be  kept  on  a  shelf  above  the  supply  table.  A 
shelf  should  be  reserved  for  books  relating  to  aseptic  technic, 
surgical  bacteriology,  operative  surgery  and  instruments. 

Instruments  (for  list  of  instruments  for  various  operations 
see  Chapter  XXIII)  are  kept  in  their  proper  places  in  the  instru- 
ment case  when  not  in  use.  Knives  are  kept  in  racks  to  prevent 
dulling.  Needles  are  kept  in  needle  trays.  So  far  as  practi- 
cable, instruments  should  be  kept  in  sets  representing  the  opera- 
tions for  which  they  are  commonly  used.  Instruments  in  part 
made  of  soft  rubber  are  kept  separate.  No  rubber  goods  are 
kept  in  the  instrument  cabinet.     Sets  of  instruments,  the  prop- 


PREPARATION    OF    INSTRUMENTS    AND    SUPPLIES 


31 


erty  of  individual  operators,  are  kept  separate  from  hospital 
instruments.  Duplicate  sets  of  instruments  are  conveniently 
placed  in  linen  holders. 

Metal  instruments   (except  edged  instruments)    are  sterilized 
by  boiling  for  ten  minutes  in  a  1  per  cent,  solution  of  carbonate  of 

\     ' 


'/ 


fx^ 


soda  just  before  using.  They  are  taken  from  the  sterilizer  in  a 
perforated  tray,  drained,  placed  on  a  sterile  sheet,  arranged, 
and  covered  with  sterile  towels.  Instruments  for  different 
operations  are  boiled  in  separate  trays,  then  placed,  tray  and  all, 
upon  the  instrument  table  and  covered  with  sterile  towels  until 


32 


OPERATING  ROOM  AND  THE  PATIENT 


required.  Trays  are  removed  from  the  sterilizer  by  long  hooks. 
Edged  instruments  with  locks,  such  as  scissors  and  bone-cutting 
forceps,  are  boiled  for  five  minutes.  They  are  boiled  separately 
from  the  other  instruments  and  on  a  rack  which  keeps  them  from 


contact  with  the  bottom  of  the  sterilizer  and  so  in  part  prevents 
vibration.  Knives  are  boiled  for  two  minutes  in  special  racks 
so  constructed  as  to  keep  their  edges  uppermost.  Needles  are 
boiled  for  three  minutes  in. an  open  metal  box.  During  steriliza- 
tion the  sterilizer  should  be  covered.     There  should  alwavs  be 


PREPARATION    OF    INSTRUMENTS    AND    SUPPLIES  33 

sufficient  soda  solution  in  the  sterilizer  to  cover  the  instruments. 
The  instrument  sterilizer  should  be  of  sufficient  depth  to  accom- 
modate several  trays. 

Directly  after  use,  instruments  are  washed,  piece  by  piece,  in 
running  cold  water  until  all  blood  stains  are  removed.  Particular 
attention  is  paid  to  locks  and  crevices.  Instruments  are  then 
boiled  for  ten  minutes  in  soda  solution.  Following  this,  they  are 
scrubbed  with  warm  water  and  "bon  ami"  until  bright;  rinsed 
in  warm  water,  thoroughly  dried  with  gauze,  polished  with  a 
soft  chamois,  and  put  in  their  places  in  dust-proof  cabinets. 
Each  week  the  cutting-edge  instruments  that  have  been  used 
during  the  week  are  sent  to  be  set  and  sharpened.  There 
should  be  a  sufficient  number  of  knives  to  allow  one  fresh  knife 
to  each  operation  during  the  week.  The  operating  room  nurse 
should  learn  to  sharpen  the  knives.  Instruments  out  of  repair 
are  sent  at  once  to  the  maker. 


Fig.   10. — Nail  cleaner.     Metal  frame  and  wire  pipe  cleaner. 

Brushes. — Brushes  are  sterilized  by  boiling  for  ten  minutes, 
after  septic  cases  for  one-half  hour,  in  10  per  cent,  bichromate 
of  potash  solution.  They  are  transferred  and  kept  in  covered 
jars  containing  the  same  strength  solution  in  1: 1000  bichlorid. 
The  bichromate  of  potash-bichlorid  solution  is  renewed  at  the 
end  of  each  operating  day.  The  use  of  this  solution  keeps  the 
brushes  in  good  condition  and  makes  them  last  longer.  Brushes 
should  be  of  the  common  hand  brush  variety,  of  good  quality, 
and  not  so  stiff  as  to  abrade  the  skin. 

Soap. — ^The  soap  commonly  used  is  the  sapo  viridis  of  the 


34  OPERATING    EOOM    AND    THE    PATIENT 

pharmacopoeia.  Tincture  of  green  soap  is  a  convenient  form. 
Ordinary  green  soap  should  be  boiled  before  using  in  order  to 
make  it  of  more  even  consistency. 

Nail  cleaners,  nail  files,  and  nail  scissors  should  be  kept  in  a 
special  tray  near  the  sinks.  The  nail  cleaner  (Fig.  10)  devised 
by  George  R.  Fowler  obviates  injury  to  the  matrix  and  insures 
thorough  cleanliness. 

Chlorinated  lime  and  sodium  carbonate  are  kept  in  separate 
air-tight  stone  jars.  A  ready  means  of  disinfecting  the  hands 
after  septic  operations  consists  in  rubbing  a  small  quantity  of 
each  of  these  ingredients  and  water  into  the  skin  for  a  few 
minutes  and  then  rinsing  with  warm  water.  The  combination 
gives  off  chlorin  gas.  It  is  c^uite  irritating  if  left  on  the  skin 
for  any  length  of  time  or  if  used  as  a  routine  procedure. 

Hand  lotions  are  at  times  useful  in  allaying  irritation  of  the 
skin  from  too  vigorous  scrubbing  or  from  chemicals.  A  simple 
lotion  is  made  as  follows: 

I^.     Acid,  acetic  dilut., 
Spiritus, 
Glycerini, 

Acid,  boric,  (sat.  sol.) aa    Bj 

Aquae  rosse oiv. 

No  hand  lotion  will  make  up  for  lack  of  care  in  the  cleansing 
of  the  hands  following  operation. 

Caps  (Fig.  11)  are  made  of  bleached  muslin  in  three  styles: 
surgeons'  caps,  nurses'  caps,  and  patients'  caps.  They  should 
be  made  in  several  sizes  and  be  large  enough  to  come  well  over 
the  occipital  protuberance,  covering  all  the  hair.  Patients' 
caps  are  made  of  unbleached  muslin.  They  resemble  the  ordi- 
nary bath  cap,  except  that  in  place  of  an  elastic  they  have  a 
drawtape  which  fastens  at  the  back  of  the  neck. 

Masks  are  made  of  oblongs  of  muslin  ten  inches  by  six  inches. 
Each  long  side  is  turned  in  and  a  drawtape  run  through. 

Rubber  aprons  are  preferably  made  of  double-faced,  red  rubber 
sheeting.  Such  sheeting  is  more  durable  than  the  single-faced. 
A  sheet  one  yard  square  makes  the  average  apron.  Elastic 
rubber  tubing  is  preferable  to  tape  for  holding  such  aprons  in 
place.     Aprons  are  cleaned  after  each  use  by  scrubbing  with 


PREPARATION    OF    INSTRUMENTS    AND    SUPPLIES 


35 


soap  and  water,  then  wiped  off  with  carbolic  acid  1 :  40,  and  hung 
up  to  dry.  A  convenient  light  apron  is  made  of  stork  sheeting 
hemmed  with  tape  and  with  tape  shoulder  straps. 

Gowns  are  of  two  varieties,  operators'  and  nurses'.  Gowns 
having  closely  fitting  long  sleeves  are  preferable  to  short-sleeved 
gowns,  as  the  gowns  are  easily  sterilized,  while  the  skin  is  not. 


Gowns  are  washed  and  laundered  in  the 
usual  manner,  then  each  gown  is  rolled 
into  a  compact  package,  inclosed  in  heavy 
sheeting  material  and  sterilized  by  steam 
for  one-half  hour  on  the  day  of  the  oper- 
ation. Gowns  are  changed  after  every  case 
in  which  infection  is  encountered.  In  a 
long  series  of  operations  it  is  more  eco- 
nomical to  wear  elbow  sleeve  gowns  and 
use  removable  sleeves  for  the  forearm 
which  are  changed  after  each  case.  If  the 
gown  is  blood  stained,  not  infected,  pinning  a  large  sterile 
towel  over  the  gown  is  permissible. 

Rubber  gloves  are  sterilized  by  boiling  for  five  minutes  in 
saline  solution  just  before  use.  Before  placing  in  the  sterilizer 
each  pair  is  loosely  wrapped  in  gauze,  the  edges  of  which  are 
secured  by  weights  to  the  bottom  of  the  sterilizer  to  prevent 
the  gloves  from  ballooning  and  floating  on  the  top  of  the  solution. 
They  are  then  immersed  and  filled  with  bichlorid,  1 :  3000,  and 
put  on.  If  the  operator  prefers  dry  gloves  they  may  be  sterilized 
by  boiling,  drained  and  then  placed  between  several  layers  of 
sterile  towels  (enough  thickness  to  ensure  a  dry  surface  between 


36  OPERATIXG    ROOM    AXD    THE    PATIEXT 

the  table  and  the  gloves)  by  a  gloved  nurse  and  their  outer 
surfaces  patted  dry.  The  gloves  are  then  turned  inside  out  and 
that  surface  patted  dry.  As  each  surface  is  dried  it  is  liberally 
powdered  with  a  drying  powder  composed  of  stearate  of  zinc 
and  boric  acid  to  keep  the  surfaces  from  adhering  and  cause 
the  gloves  to  slip  on  easily.  Finally  the  gloves  are  wrapped 
in  pairs  in  sterile  well-powdered  towels  and  kept  in  a  sterile 
receptacle.  The  drying  powder  used  is  sterilized  by  baking  at  a 
high  temperature  for  one  hour  on  three  successive  days.  Gloves 
should  have  gauntlets  which  come  well  up  on  the  forearm. 
They  should  be  tested  before  use  by  filling  them  with  bichlorid 
solution  to  detect  any  needle  holes  or  tears.  They  are  worn 
during  all  operations,  but  they  should  not  be  put  on  until  after 
thorough  mechanic  disinfection  of  the  hands.  If  injury  to  a 
glove  occurs,  the  hands  are  disinfected  and  fresh  gloves  donned. 
Fresh  gloves  are  donned  before  each  operation.  The  use  of  a 
drying  powder — i.e.,  alum — as  advocated  by  Dawbarn,  prevents 
sweating  to  a  certain  extent.  If  the  hands  sweat  excessively  so 
that  in  the  event  of  the  gauntlet  not  fitting  snugly  on  the  forearm 
it  is  possible  for  the  secretions  to  escape  and  wet  the  sleeve  or 
even  to  soil  the  operating  field  a  piece  of  gauze  may  be  wound 
about  the  wrist  and  the  glove  drawn  over  it.  The  gauze  absorbs 
the  secretions  and  prevents  their  escape.  Blood  and  secretions 
should  not  be  allowed  to  dry  upon  the  gloves.  To  avoid  this 
frequent  rinsing  of  the  gloved  hand  is  necessary.  Before 
removing  gloves  they  should  be  washed  in  running  water  to 
remove  all  blood  and  secretions.  The  wet  method  of  sterilization 
is  preferable  to  the  dry  as  the  surgeon  can  then  himself  easily 
determine  by  distending  the  glove  with  fluid  whether  the  glove 
is  perfect.  Directly  after  using,  gloves  should  be  washed  in 
soap  and  water,  then  boiled  in  saline  solution  for  two  minutes, 
rinsed  in  water,  the  outside  dried,  turned  inside  out,  and  hung 
up  to  dry.  Allowing  them  to  remain  wet  causes  them  to  deterio- 
rate. The  surfaces  may  be  kept  from  coming  in  contact  and 
adhering  by  lightly  packing  the  fingers  with  gauze.  Needle 
punctures  and  slight  tears  are  repaired  b}'  stretching  the  glove 
over  a  test-tu^e  and  cementing  over  the  aperture  a  patch  of 
thin   rubber   dam.     If  the   cement   is   applied   evenly   and  the 


PREPARATION    OF    INSTRUMENTS    AND    SUPPLIES  37 

patch  held  slightly  stretched  until  the  cement  takes  hold  the 
glove  will  stand  sterilizing  without  loosening  of  the  patch. 
Special  cement  comes  for  the  purpose.  A  patched  glove  should 
be  worn  with  the  patches  inside  to  avoid  the  possibility  of  the 
patch  becoming  displaced  and  being  lost  in  the  wound. 

Finger  cots  of  thin  rubber  are  useful  in  examinations  and  to 
protect  small  abrasions  on  the  fingers  from  infection.  They 
may  be  put  on  the  first  and  little  fingers  of  each  hand  in  cases 
in  which  many  ligatures  are  to  be  tied  and  will  aid  in  preventing 
the  cut  which  the  tying  of  many  ligatures  occasionally  makes 
in  the  creases  of  these  fingers.  They  are  prepared  and  cared 
for  in  the  same  manner  as  rubber  gloves,  except  they  stand  but 
one  minute's  boiling. 

Protectors  are  made  of  heavy  linen  or  of  bleached  muslin  in 
two  sizes,  one  and  one-half  yards  by  one  and  three-fourths  yards, 
and  one  and  one-half  yards  by  three-fourths  yard.  They  serve 
to  cover  the  patient  except  the  part  to  be  operated  upon.  They 
are  sterilized  in  sets  of  two,  one  large  and  one  small,  rolled  into  a 
compact  package  done  up  in  heavy  sheeting  material. 

Perineal  sheets  are  used  to  cover  the  feet,  legs,  thighs, 
buttocks  and  lower  abdomen  of  patients  in  the  lithotomy 
position.  They  are  two  yards  in  length  by  one  in  breadth. 
Each  short  side  has  a  pocket  arrangement  which  covers  the 
patient's  foot.  Through  the  center  of  that  portion  which  covers 
the  perineum  is  a  twelve-inch  slit.  Each  sheet  is  sterilized  in 
an  individual  package. 

Anus  protectors  for  use  in  vaginal  operations  are  two-tailed 
bandages  of  several  thicknesses  of  gauze,  the  tails  lying  upon  the 
abdomen,  the  body  of  the  protector  over  the  anus.  The  tails 
should  be  long  enough  to  lie  well  up  on  the  abdominal  surface 
to  preclude  slipping.  The  body  of  the  protector  is  held  in  place 
by  the  speculum.  An  anus  protector  should  be  sterilized  in 
the  package  with  the  perineal  sheet. 

Towels  are  made  of  dish  toweling  of  good  quality.  They  are 
thirty  inches  in  length  by  twenty  inches  in  width,  and  hemmed. 
They  are  folded  separately  and  sterilized  in  packages  of  six. 

Blankets  for  use  in  the  operating  room  are  the  ordinary  single 
blankets  cut  in  half.     This  size  is  most  convenient  for  wrapping 


38 


OPERATING    ROOM    AXD    THE    PATIEXT 


around  the  legs  of  patients  or  placing  over  the  chest.     They  are 
laundered  and  sterilized  after  each  use. 

Screen  covers  are  changed  weekly  or  as  often  as  soiled.  The 
light-weight  canvas  kind  which  are  provided  with  eyelets  and 
lace  to  the  frame  are  best. 

Rubber  sheeting  is  kept  in  stock  for  making  pads  for  the  oper- 
ating table  and  for  rubber  aprons.     Several  sheets  one  yard  by 

thirty  inches  should  be  kept 
on  hand  to  place  under  the 
patient  to  act  as  drainage 
pads  when  using  irrigations. 

Covers  for  the  rubber  pads 
used  on  the  operating  table 
and  carts  are  of  stout  muslin. 
These  are  fresh  for  each  cause. 
Muslin  bottle  hags  should  be 
kept  in  stock  in  various  sizes 
and  fresh  ones  used  for  each 
series  of  operations.  Muslin 
hand,  foot,  arm  and  leg  bags, 
with  drawstrings,  are  useful 
in  operations  in  the  neighbor- 
hood of  these  parts. 

Sheets,  gowns,  towels, 
blankets,  etc.,  are  secured  in 
convenient  packages  and 
sterilized  by  steam  at  least 
one  hour  before  operations. 
If  these  sterilized  bundles 
have  not  been  opened  for 
forty-eight  hours  they  are 
resterilized  before  using. 
The  Sterilization  of  Gowns,  Sheets,  Towels,  Gauze  and  Dressing 
Materials. — This  is  best  accomplished  by  exposure  to  flowing 
steam,  or  steam  under  ten  j^ounds  pressure  and  upward,  for 
one  hour.  A  convenient  apparatus  for  the  former  is  the  Arnold 
steam  sterilizer  (Fig.  14).  In  order  to  prevent  the  materials 
from  becoming  wet  in  the  sterilizer  bv  condensation  of  the  steam 


Fig.  12. — Small  steam-pressure  ster- 
ilizer and  instrument  boiler.  (Fowler's 
Surgery.) 


PREPARATION    OF    INSTRUMENTS    AND    SUPPLIES 


39 


Fig.  13. — Schimmelbusch's  sterilizer  for 
boiling  instruments  in  soda  solution. 
(Fowler's  Surgery.) 


thereon,  they  should  be  first  warmed.     For  sterilizing  on  a  large 

scale  for  hospital  purposes  the  steam-pressure  apparatus  (Fig.  15) 

is  to  be  used.  A  con- 
venient combination  of 
steam-pressure  sterilizer 
and  instrument  boiler 
for  office  use  is  shown  in 
Fig.  12.  For  boiling  in- 
struments in  soda  solu- 
tion and  sterilizing 
gowns  and  dressing  ma- 
terials by  steam  at  the 
same  time  the  sterilizer 
of  Schimmelbusch  (Fig. 
13)  is  convenient  and 
efficient.  Squares  of 
gauze  to  be  used  in  place 

of  flat  sponges  in  abdominal  section,  which  require  to  be  warm 

when  brought  in  contact  with  the  intestines   may  be  boiled  in 

a  0.6  per  cent,   solution  of   com- 
mon salt  (Tavel)  and  kept  therein 

until  ready  for  use,  when  they  are 

wrung  out  (Fig.  16). 

Powders  for  use  in  making  up 

dressings   and    solutions    are  kept 

dry    in    wide-mouthed,   screw-cap 

glass  jars. 

Iodoform. — ^This  should  be  finely 

powdered    by    mortar   and   pestle 

before  using.    The  container  should 

be  light  proof. 

Zinc  oxid  for  making  zinc  oxid 

gauze    and  for   use  as  a  dusting 

powder. 

Saline    'powders    for  making  up 

solutions  for  intravenous  infusion, 

,  ~  n  Fig.  14. — Arnold  steam  sterilizer. 

made  as  follows:  (Fowler's   Surgery.) 


40  OPERATING    ROOM    AND    THE    PATIENT 

I^.     Sodii  chlorid 5iv  gr.  vj 

Sodii  sulphat '. gr-  xj 

Sodii  phosphat gr.  iiif 

Sodii  carbonat gr.  vss 

Calcii  phosphat gr.  ix| 

Magnes.  phosphat gr.  iv|. 

M.     SiG.-^One  powder  to  six  quarts  and  nine  ounces  of  sterile  water. 


Fig.   15. — Hospital  steam-pressure  sterilizer,  instrument  boiler,  and  water 
sterilizer.      (Fowler's  Surgery.) 


Potassium  permanganate  crystals  in  one  ounce  packages. 
Oxalic  acid  crystals  in  one  and  one-half  ounce  packages. 


PREPARATION    OF    INSTRUMENTS    AND    SUPPLIES  41 

Thiersch  powders  containing  15  grains  of  salicylic  acid  and  90 
grains  of  boric  acid. 

Boric  acid  for  making  Thiersch  powder,  gauze,  and  solutions. 

Bichlorid  of  mercury  made  up  in  tablets  of  7  1/2  grains  (one 
to  one  pint  of  fluid  makes  a  1 :  1000  solution)  and  for  making  stock 
solutions. 

Carbonate  of  soda  (5iiss  to  the  quart  makes  a  1  per  cent, 
solution)  for  sterilizing  instruments. 


Fig.  16. — Wringer  for  hot  towels,  gauze,  etc.      (Fowler's  Surgery.) 

Bicarbonate  of  soda,  saturated  solution  equals  5ii  5iiss  to  the 
quart. 

Sodium  chlorid  made  up  in  one  dram  packages  and  sterilized 
by  diy  heat. 

Bichromate  of  potash  (oiss  gr.  xlviii  for  making  the  solution 
for  hand  brushes  (one  package  to  the  pint  makes  10  per  cent, 
solution). 

Cocain  hydrochlorate  in  one-half  grain  tablets  for  making  up 
spray  and  hypodermic  solutions. 

Novocain  in  one-third  grain  tablets. 

Solutions. — ^All  water  used  in  making  solutions  is  sterilized 
and  all  solutions  are  carefully  labeled. 

Bichlorid  of  Mercury. — ^The  stock  solution  may  be  either  5 
per  cent,  or  12  1/2  per  cent,  bichlorid  in  alcohol.  It  should 
be  kept  in  a  light  proof  bottle.  Of  the  first,  §j  to  the  gallon 
makes  a  1 :  3000;  of  the  second,  5iv  to  the  gallon  makes  a  1 :  2000 
solution;  other  strengths  in  proportion.  A  small  quantity  of 
anilin  blue  added  to  the  stock  solution  is  sufficient  to  color  all 
the    solutions    and    distinguishes    them    from    other    solutions. 


42  OPERATING    ROOM    AXD    THE    PATIEXT 

Sufficient  liydrocliloric  acid  should  be  added  to  cause  an  acid 
reaction  in  all  bichlorid  solutions. 

Acid  hichlorid  is  made  in  the  proportion  of  '^'ater,  30  parts; 
alcohol  (94  per  cent.),  60  parts;  hydrochloric  acid,  6  parts; 
bichlorid,  to  make  a  strength  of  1:1250  (Harrington's  formula). 

Carbolic  acid  solution  should  be  made  hot.  Stock  solution, 
95  per  cent.,  5vj  to  1  gallon  makes  a  1 :20  solution;  other  strength 
in  proportion.  The  addition  of  an  equal  part  of  glycerin  causes 
the  carbolic  to  mix  better  with  the  water.  Also  used  pure  in 
the  disinfection  of  suppurating  cavities.  AYhen  used  in  this 
manner  a  quantity  of  absolute  alcohol  should  be  at  hand. 

Boric  acid,  §vj  to  the  gallon,  makes  a  saturated  solution. 
Add  the  crystals  while  the  water  is  hot;  then  filter. 

Thiersch  solution  (boro-salicylic  solution);  salicjdic  acid,  15 
grains;  boric  acid,  90  grains  to  the  pint.  Add  the  powder  to 
cold  water,  then  filter. 

Normal  Saline  Solution. — Sterile  sifted  salt,  5j  to  the  pint. 
Dissolve  in  sterile  water.  Filter  in  sterile  flasks,  stopper  with 
sterile  nonabsorbent  cotton,  sterilize  for  one  hour  for  three  succes- 
sive days  at  a  temperature  of  220°  F.,  and  cover  the  cotton 
stopper  and  neck  of  the  flask  with  a  rubber  finger  cot.  When 
needed,  place  the  flask  in  a  deep  basin  filled  with  hot  water  until 
raised  to  the  required  temperature,  120°  F.  A  special  saline 
powder  maybe  used,  but  is  not  essential.  In  an  emergency  a 
dram  of  sterile  salt  is  added  to  a  pint  of  hot  sterile  water,  the 
solution  is  filtered  and  brought  to  the  required  temperature. 

Bichlorid-permanganate  Solution. — Potassium  permanganate 
crystals,  5j;  bichlorid  of  mercury,  gr.  viiss;  to  1  quart  of  hot 
sterile  water.     The  solution  should  be  made  shortly  before  using. 

Permanganate  of  Potassium  Solutioii. — Crystals,  §j;  hot  sterile 
water,  1  quart.     Should  be  made  shortly  before  using. 

Oxalic  Acid  Solution. — Crystals,  Biss;  hot  water,  1  quart. 
Should  be  made  shortly  before  using. 

Ammonia  Solution. — Stronger  ammonia,  oj;  cold  water, 
2  quarts.  Should  be  made  shortly  before  using.  For  neutral- 
izing the  effects  of  the  oxalic  acid. 

Lime-water,  for  neutralizing  oxalic  acid. 

Iodoform  emidsion,  10  per  cent. 


PREPARATION    OF    INSTRUMENTS    AND    SUPPLIES  43 

I^.     lodoformi  (finely  powdered) oj 

Glycerini olx. 

Put  glycerin  in  wide-mouthed  bottle,  cork,  and  sterilize  by  steam  for 
fifteen  minutes;  add  iodoform  gradually,  shaking  the  mixture  every  few 
minutes. 

Formalin  Glycerin  Mixture  (formalin  10  per  cent.)  for  injection 
into  joint  cavities. 

Chlorid  of  zinc  solution,  10  per  cent.,  for  use  as  an  escharotic. 

I^.     Zinci  chloridi gr.  384 

Aquae  destillatse §  viij . 

Bichromate  of  potash  solution,  10  per  cent. 

'Bf.     Potassii  bichromatis oiss  gr.  xxx 

Aquae  destillatae 1  pint. 

This  solution  is  used  for  sterilizing  and  preserving  hand  brushes. 

Woelfler's  solution  is  compound  tincture  of  benzoin  to  which 
10  per  cent,  iodoform  powder  has  been  added.  It  should  be 
shaken  before  using.  For  use  as  a  peritoneal  varnish;  to  fill  the 
umbilicus  after  cleansing;  to  coat  the  nipple  in  breast  operations. 

Tincture  of  iodin,  for  skin  disinfection.  Bichlorid  to  make  a 
1:1000  solution  may  be  added. 

Benzin,  for  use  in  the  thermocautery  and  for  cleansing  ecze- 
matous  conditions  of  the  skin.  Great  care  must  be  exercised 
in  handling  benzin,  as  it  is  very  inflammable.  It  is  useful  in 
removing  adhesive  plaster. 

Alcohol,  50  per  cent,  for  general  use  in  cleansing  and  adding  to 
hand  solutions;  80  per  cent,  for  the  hands;  absolute  for  steriliza- 
tion of  catgut. 

Sterile  water  is  kept  in  well-stoppered  flasks.  The  hot  and 
cold  sterile  water  apparatus  should  give  a  generous  supply. 

Hydrogen  peroxid  kept  in  brown  or  blue  glass  bottles.  An 
air  space  should  be  left  above  the  solution. 

Sodium  bicarbonate  5ii  5iiss  makes  a  saturated  solution  for 
diluting  hydrogen  peroxid  just  previous  to  use  and  to  neutralize 
the  effect  of  chlorid  of  zinc. 

Commercial  ether,  for  cleansing  purposes. 

Glycerin,  for  use  as  a  lubricant;  for  tampons;  for  preparing 
catgut;  for  diluting  carbolic  acid. 


44  OPEKATIXG    ROOM    AND    THE    PATIENT 

Balsam  of  Peru,  plain  and  mixed  with  an  equal  part  of  castor 
oil  for  gauze  dressings. 

Ichthyol,  for  adding  to  glycerin  to  make  10  per  cent,  tampons. 

Vaselin  in  ounce  glass  jars  for  use  as  a  lubricant.  Should  be 
sterilized  after  each  use. 

Olive  oil,  for  use  as  a  lubricant,  and  to  prevent  adhesions  in 
laparotomy,  should  be  sterilized  after  each  use. 

Whale  oil  and  iodoform  mixture  (Mosetig-Moorhoff)  for  filling 
bone  cavities.     To  be  melted  just  before  use. 

Iodoform 60  parts 

Spermacetti, 

Oil  of  Sesame aa  40  parts. 

Horseley  hone  wax,  for  controlling  hemorrhage  from  bone. 

Paraffin,  of  a  melting-point  of  120^  F.,  for  preparing  silk 
sutures;  for  preparing  paper  coverings  for  dressings;  for  injection 
purposes. 

Cocain  Solutions. — Solutions  of  cocain  should  be  freshly 
prepared.  A  1/2  per  cent,  solution  is  2  2/5  grains  to  the  ounce; 
1  per  cent,  solution,  4  4/5  grains  to  the  ounce;  other  strengths 
in  proportion. 

Collodion  in  light-proof  bottles  for  sealing  wounds. 

Gauzes. — ^All  gauze  previous  to  use  or  to  impregnation  with 
antiseptics  is  sterilized  by  steam  for  a  half  hour  each  day,  at  a 
temperature  of  212°  F.,  for  three  successive  days  (fractional 
sterilization).  In  the  preparation  of  all  gauzes,  strict  asepsis  of 
the  hands  and  all  utensils  is  observed.  Rubber  gloves  should 
b^  worn. 

Iodoform  Gauze  No.  1.     Formula: 

Iodoform  powder gr.  116 

Glycerin o  j 

Alcohol. 5ij. 

Mix  thoroughh\  This  quantity  of  iodoform  makes  a  10  per 
cent,  gauze.  For  more  strongly  impregnated  gauze  use  iodoform 
in  proportion.  This  quantity  is  sufficient  to  impregnate  one 
yard  of  gauze.  The  iodoform  emulsion  is  evenly  distributed 
through  the  gauze  by  repeatedly  pressing  the  gauze  into  the 
liquid  and  wringing  it  out.     The  gauze  is  then  folded  or  rolled  in 


PREPARATION    OF    INSTRUMENTS    AND    SUPPLIES  45 

convenient  shape  and  placed  in  sterile,  glass,  air-tight,  light- 
proof  receptacles.  Finally,  the  gauze  is  sterilized  by  steam 
heat  for  one  hour  at  a  temperature  not  exceeding  212°  F. 

Iodoform  Gauze  No.  2.     Formula: 

Iodoform  powder o  ss 

Glycerin 5  j 

Hydrarg.  bichlorid  (1 :  2000) Oj. 

Mix  thoroughly.  Cut  the  gauze  by  drawn  thread  into  strips 
five  yards  long  and  four  inches  wide  and  fold  or  roll.  Sterilize. 
Immerse  in  the  above  mixture,  then  sterilize  for  one  hour  by 
steam  heat,  212°  F. 

lodoforvi  Gauze  No.  3.     Formula: 

Iodoform  powder oj 

Glycerin o  viij 

Alcohol Oj 

Sterile  water o  viij . 

Mix  the  iodoform  and  glycerin,  then  add  the  alcohol  and  sterile 
water.     Proceed  as  above. 

Iodoform  Gauze  No.  4.     Formula: 

Iodoform  powder oiv 

Glycerin Sx 

Alcohol 5xxxv 

Ether Oj. 

Mix  the  iodoform  powder  and  glycerin.  Let  stand  for  twenty- 
four  hours,  then  mix  again  and  add  alcohol  and  ether.  Proceed 
as  above.     This  formula  is  best  for  impregnating  gauze. 

Zinc  Oxid  Gauze.     Formula: 

Zinc  Oxid  Powder oss 

Glycerin o  j 

Sterilized  water  (warm) Oj . 

Mix  thoroughly.  Cut  the  gauze  by  drawn  thread  in  strips  five 
yards  long  and  three  and  one-half  inches  wide;  immerse  in  the 
solution,  squeeze  out,  roll  or  fold,  place  in  sterile  glass  jars, 
sterilize  for  one-half  hour  by  steam  heat  on  three  successive 
days,  and  seal.  Only  small  quantities  of  this  gauze  should  be 
made  up  at  one  time  as  it  deteriorates. 

Boric  Acid  Gauze. — Cut  gauze  in  strips  as  above,  boil  for  one- 


46  OPERATIXG  ROOM  AXD  THE  PATIENT 

half  hour  in  a  saturated  solution  of  boric  acid,  then  sterilize 
as  for  zinc  oxid  gauze. 

Bichlorid  of  Mercury  Gauze.  Formula: 

Strength 1 :  1000  1 :  500  1 :  400 

Absorbent  gauze  (dry) 13  av.  oz.  13  av.  oz.  13  av.  oz. 

Sol.  bichlorid  (1 :  1000) 12  1/2  oz.  25  oz.  31  oz. 

Sterilized  water q.s.  ad  32  oz.  32  oz.  32  oz. 

After  the  gauze  has  been  thoroughh^  saturated,  dry  in  a  dust- 
proof  place  and  preserve  in  light-proof  jars. 

Thiersch  Gauze. — ^Prepare  Thiersch  solution,  1:50  (proportion: 
boric  acid,  gr.  viij ;  salicylic  acid,  gr.  j ;  use  292  grains  of  the 
powder  to  1  quart  of  water).  Saturate  sterile  gauze  in  this 
solution  for  twenty-four  hours,  place  in  sterile  jars,  and  seal. 

Balsam  of  Peru  Gauze.     Formula: 

Balsam  of  Peru oiv 

Xaphthalin Siiiss. 

The  balsam  is  sterilized  for  twenty  minutes  at  a  temperature 
of  212°  F,  Cut  gauze  in  strips  five  Awards  long  and  three  and 
one-half  inches  wide,  sterilize,  immerse  in  the  above  mixture, 
wring  out  as  dry  as  possible,  roll  or  fold,  place  in  sterile  jars,  and 
seal.     Prepare  the  gauze  before  the  mixture  cools. 

Carbolized  Gauze.     Formula: 

Resin o  xiiiss 

Carbolic  crystals o  iiiss 

Alcohol Oiv 

Castor  oil oii2/3. 

Mix  thoroughly.  This  quantity  is  sufficient  to  impregnate 
thirty  j'ards  of  gauze.  Place  impregnated  gauze  in  sterile  jars 
and  seal. 

Drains.  Gauze  Drains. — Strips  of  various  dimensions,  the 
edge  turned  in  and  hemmed  to  obviate  fraying,  are  used  for 
wound  tamponade.  Cut  gauze  strips  by  drawn  thread.  Gauze 
drains  may  be  impregnated  with  antiseptics. 

Wicking  Drains. — Material  is  string  lamp-wicking  which  comes 
in  lengths  of  several  j-ards  rolled  up  in  a  ball.  Cut  in  lengths  of 
nine  inches,  place  in  bundles  of  four  wicks  each,  fasten  the  ends 
with  silk,  boil  for  one-half  hour  in  saline  solution,  place  in  jars, 


PREPARATION    OF    INSTRUMENTS    AND    SUPPLIES  47 

sterilize,  and  seal.  The  wicking  may  be  impregnated  with 
antiseptics.  Several  strips  of  wicking  or  gauze  may  be  inclosed 
in  green  silk  protective  or  rubber  tissue  stitched  in  place  (cigarette 
drains).     The  covering  may  be  fenestrated  if  desired. 

Modified  Cigarette  Drains  (Fig.  17). — ^The  protective  only 
covers  that  part  of  the  drain  which  lies  in  the  external  part  of 
the  wound,  the  longer  portion  of  the  gauze  or  wicking  being  used 
to  pack  the  cavity.  They  are  sterilized  for  twenty  minutes  at  a 
temperature  of  212°  F. 

The  Mikulicz  drain  acts  as  a  capillary  drain  and  by  compres- 
sion arrests  oozing.     It  is  made  of  a  square  of  one  or  two  layers 


Fig.  17. — Modified  cigarette  drain. 

of  gauze,  plain  or  medicated,  in  which,  after  it  is  placed  in  the 
cavity  to  be  filled,  are  packed,  as  in  a  bag,  strips  of  gauze  the 
ends  of  which,  as  well  as  the  corners  of  the  bag,  emerge  from  the 
wound. 

The  three  above-mentioned  drains  are  useful  in  packing  or 
draining  cavities  and  yet  allow  of  ready  removal  through  a  small 
opening. 

Rubber  Tissue  Drains. — Rubber  tissue  is  cut  in  strips  two  by 
three  to  six  inches,  boiled  in  water  for  five  minutes,  preserved 
in  50  per  cent,  alcohol  in  normal  saline  solution,  or  after  boiling 
it  may  be  rolled  between  layers  of  gauze,  placed  in  jars,  and 
sterilized  for  twenty  minutes  at  a  temperature  not  higher  than 
212°  F,  Heat  will  destroy  veiy  light  rubber  tissue  if  prepared  in 
this  way.  It  yields  readily  to  the  influence  of  overwarm  or 
hot  fluids  and  is  often  awkward  to  manage  when  in  contact 
with  either.  Consequently  it  is  of  less  practical  use  than  the 
green  silk.  Moreover,  it  is  too  rapidly  disintegrated  by  wound 
secretion  to  act  efficiently  as  a  drain  for  any  length  of  time. 

Umbrella  Tampon. — ^This  type  of  tampon  (Fig.  18),  formed  by 
a  rubber  tube  to  which  is  sewed  a  curtain  of  gauze,  is  useful  in 
controlling  hemorrhage  in  rectal  and  perineal  wounds.  The 
interior  of  the  curtain  is  packed  firmly  with  gauze  strips  after 


48 


OPERATIXG  ROOM  AND  THE  PATIEXT 


the  tampon  has  been  placed  in  the  wound,  the  rubber  tube 
allowing  the  escape  of  gas  or  urine,  as  the  case  may  be. 

Cotton,  nonabsorhent,  is  prepared  by  cutting  the  original  roll 
in  half  lengthwise,  then  unrolling  each  half  and  cutting  crosswise 
into  four  sheets.  Each  sheet  is  rolled  up,  not  very  tightly,  and 
covered  with  heavy  sheeting  material.  Sterilize  by  steam  at  a 
temperature  of  240°  F.  for  one-half  hour.  This  cotton  is  used 
for  the  outer  protection  of  wounds  and  for  padding  splints. 


IS. — Umbrella  tampon. 


Cotton,  Ahsorhent. — Small  pieces  are  used  on  wooden  applica- 
tors for  cleansing  wounds  or  applying  caustics.  A  number  of 
these  are  prepared  and  sterilized  in  their  container.  Absorbent 
cotton  is  rolled  up  in  small  packages  and  sterilized  by  steam  for 
one-half  hour. 

Lambs'  wool  is  cut  into  convenient  sizes,  two  inches  by  four, 
for  tampons.  An  eight -inch  piece  of  cotton  string  is  tied  around 
the  middle  of  the  tampon  to  facilitate  its  withdrawal.  The  ends 
of  the  string  should  be  knotted  together.  They  are  useful  for 
vaginal  tamponade. 

Sponges. — Hand  sponges  are  made  of  a  single  thickness  of 
gauze  eighteen  inches  sc^uare.     Two  opposite  sides  are  folded 


PREPARATION    OF    INSTRUMENTS    AND    SUPPLIES  49 

one  over  the  other  so  as  to  lessen  the  width  of  the  gauze  two- 
thirds;  the  short  sides  of  the  resulting  rectangle  are  folded  toward 
each  other  and  the  end  of  one  short  side  is  inserted  into  .the  end 
of  the  other  short  side  in  the  same  manner  that  one  tucks  in 
the  flap  of  an  envelope.  With  a  little  practice  sponges  can  be 
made  more  quickly  in  this  manner  than  by  sewing  them.  They 
are  put  up  in  packages  of  twenty-five. 

Stick  sponges  are  made  from  gauze  one-sixteenth  of  a  yard 
square  in  three  ways;  either  like  the  hand  sponges,  or  three  corners 
of  the  small  square  may  be  folded  to  the  center  and  then  rolled 
into  a  ball  which  is  held  in  shape  by  inclosing  it  with  the  fourth 
corner  in  the  same  manner  that  a  pair  of  socks  are  held  in  shape 
when  rolled  up,  or  a  small  quantity  of  absorbent  cotton  may  be 
inclosed  in  a  three-inch  square  of  gauze  and  secured  by  stitching. 
They  are  put  up  in  packages  of  fifty. 

Laparotomy  sponges  are  made  in  three  sizes,  eight,  ten,  or 
twelve  inches  square,  of  six  thicknesses  of  gauze,  the  edges 
turned  in  and  hemmed  so  that  there  are  no  loose  threads.  To 
one  corner  of  the  sponge  is  sewn  a  tape  twelve  inches  in  length. 
Twelve  laparotomy  sponges  of  the  same  size,  the  tapes  numbered 
from  one  to  twelve  are  made  into  a  package. 

Crash  wash-cloths  are  useful  for  this  purpose.  They  should 
have  the  usual  twelve-inch  tape  attached. 

Particular  care  must  be  exercised  in  counting  these  sponges, 
both  when  they  are  made  up  into  packages  and  when  these 
packages  are  opened.  Any  inaccuracy  in  the  count  must  be 
at  once  reported. 

Compresses  are  made  of  a  single  thickness  of  gauze  one  yard 
square.  Two  opposite  sides  are  folded  so  as  to  overlap  each 
other,  thus  turning  in  the  raw  edges  and  decreasing  the  width 
of  the  gauze  by  two-thirds;  the  opposite  sides  are  then  folded, 
over  each  other  toward  the  center.  Compresses  are  done  up 
in  packages  of  two,  for  ward  dressings;  three,  for  laparotomy 
dressings,  and  twelve  for  general  operating  room  use. 

Graduated  tampon,  a  pyramid  built  up  of  different  sized  layers 
of  gauze,  held  in  place  by  a  few  stitches  through  the  center,  is 
useful  in  exerting  even  pressure  or  in  checking  hemorrhage. 

Laparotomy  pads  are  used  to  save  gauze;  they  are  made  by 


50  OPERATING    ROOM    AND    THE    PATIENT 

inclosing  a  twelve-inch  square  of  nonabsorbent  cotton  in  a 
gauze  bag. 

Paper  Dressing. — Bags  cf  gauze,  twelve  by  eight  inches,  are 
loosely  filled  with  shredded  tissue  paper.  This  form  of  dressing 
is  very  absorbent,  and  therefore  useful  in  dressing  cases  in 
which  a  large  discharge  is  expected.  They  serve  admirably 
for  vulvar  pads. 

Cleansing  of  Gauze. — ^.Ul  gauze  (except  the  stick  sponges) 
which  has  not  been  used  in  septic  cases  is  soaked  in  several 
changes  of  cold  water  and  stirred  occasionally  to  remove  the 
blood,  then  washed  in  running  cold  water  until  all  stains  are 
removed,  rolled  in  packages,  boiled  for  one-half  hour  in  normal 
salt  solution,  wrung  out,  and  placed  in  the  steam  sterilizer  to  dry. 
When  dry,  the  gauze  is  made  up  into  sponges  and  compresses 
and  sterilized  in  the  usual  manner.  Laparotomy  sponges  are 
cleansed  in  the  same  manner. 

Waxed  or  paraffin  paper  is  used  to  enclose  packages  of  dressings, 
sponges,  etc.,  after  sterilization  to  keep  them  free  from  moisture. 
It  is  used  as  a  substitute  for  oiled  silk  or  gutta-percha  tissue  in 
making  pneumonia  jackets,  protective  covering  for  wet  dressings, 
etc.  It  is  much  cheaper  than  either  of  these  materials.  Par- 
affin is  cheaper  than  wax.  To  prepare,  spread  sheets  of  paper 
on  a  flat  surface,  melt  the  wax  or  paraffin,  pour  it  on  the  paper; 
iron  evenly  with  a  hot  flat-iron.  The  prepared  paper  should 
not  be  exposed  to  high  temperatures. 

Rubber  Goods. — ^The  stock  supply  of  rubber  tubing  and  other 
rubber  goods,  such  as  catheters,  stomach  tubes,  perineal  tubes, 
Esmarch  constrictors,  and  Martin  elastic  bandages,  should  be 
kept  in  a  drawer  by  themselves  and  liberally  sprinkled  with 
powdered  sulphur.  Treated  in  this  way,  rubber  can  be  kept  in 
good  condition  for  years.  Rubber  tubing  should  not  be  kinked 
nor  should  rubber  sheeting  be  creased.  Rubber  drainage  tubes 
of  various  diameters  cut  in  desired  lengths  from  the  stock  supply, 
are  scrubbed  with  soap  and  water,  rinsed,  boiled  in  1  per  cent, 
carbonate  of  soda  solution  for  one-half  to  one  hour,  rinsed,  and 
preserved  in  alcohol,  50  per  cent.,  or  carbolic  acid,  1:40,  in 
normal  saline  solution  in  sterile  sealed  jars.  The  solution  is 
changed  at  lea&t  once  each  week.     Fenestra  are  cut  just  before 


PREPARATION    OP    INSTRUMENTS    AND    SUPPLIES 


51 


using.  When  used  for  draining  an  infected  area  fenestra  should 
be  placed  only  in  the  infected  portion  of  the  wound,  to  do  other- 
wise is  to  promptly  invite  infection  throughout  the  entire  area 
through  which  the  tube  passes,  A  form  of  self -retaining  rubber 
tube  useful  in  draining  cavities,  particularly  pelvic  abscesses 
per  vaginam,  has  been  designed  by  Harrison  (Fig.  19).  Rubber 
dam  is  sterilized  by  boiling  for  one-half  hour  in  saline  solution, 
rinsed    and  ^  preserved    in    carbolic    solution,    1:20,     Green  silk 


Fig.  19. — The  self-retaining  drainage-tube.  A,  Rubber  tube  shaped 
ready  for  forming  the  self-retaining  wings ;  B,  the  spUt  lateral  portions  of 
the  tube  reversed  and  passed  through  the  openings  on  the  side  to  form  the 
wings ;  C,  the  tube  grasped  by  the  forceps  ready  to  be  placed  in  position. 
(Fowler's  Surgery.) 

protective  is  cut  in  strips  fourteen  inches  long  by  two  inches  wide, 
washed  with  soap  and  water,  placed  in  bichlorid  solution  1 :  000 
for  one  hour,  rinsed  in  saline,  laid  between  strips  of  sterile  gauze 
of  slightly  larger  dimensions,  rolled  loosely,  and  sterilized,  in 
jars  at  a  temperature  of  212°  F.  for  twenty  minutes.  It  is 
useful  as  a  capillary  drain.  Two  or  more  strips  one-half  inch 
wide  and  of  sufficient  length  should  be  used.  When  applied  in 
the  form  of  narrow  strips,  imbricated  or  not,  as  in  skin-grafting 
and  blood  clot  organization  (Schede),  equitable  temperature 
is  maintained  and  free  escape  of  discharges  into  superimposed 
absorbent  dressings  is  promoted. 

Filiform  bougies  should  never  be  boiled.  They  are  washed 
with  soap  and  water  and  placed  in  carbolic  solution  1 :  40  shortly 


52 


OPERATING    ROOM    AND    THE    PATIENT 


before  using.  Just  before  using  they  are  rinsed  in  sterile  water. 
After  using,  they  are  washed  with  soap  and  water,  rinsed,  and 
carefully  dried.  They  should  be  kept  in  a  box  or  metal  cylinder 
by  themselves. 

Tourniquets  and  rubber  bandages  are  washed  with  soap  and 
water,  rinsed  in  1 :  100  carbolic,  and  rolled  up  just  before  using. 
After  using,  they  are  washed  with  soap  and  water  and  thoroughly 

dried.     They  may  be  prepared  by  boil- 
ing in  plain  water  for  two  minutes. 

Rubber  bolsters  are  used  in  tying  cross- 
sutures  in  pairs.  They  are  one  inch  in 
length,  three  inches  for  perineal  bol- 
sters, cut  from  thick-walled  rubber 
aspirating  tubing.  The  cut  edges 
should  be  rounded  with  scissors.  They 
are  boiled  for  ten  minutes  just  before 
using.  They  should  be  preserved  after 
removal,  cleansed  and  resterilized. 

Glass  goods  comprise  various  sized 
drainage  tubes,  catheters,  connections, 
irrigation  nozzles,  syringes,  medicine 
droppers,  and  medicine  glasses.  They 
are  stei'ilized  by  boiling  in  soda  solu- 
tion and  kept  in  bichlorid,  1:1000,  in 
covered  glass  receptacles.  This  process 
should  be  repeated  at  least  once  each 
week. 

Flanged  glass  drainage  tubes  serve 
the  purpose  better  than  rubber  tubes  in  the  majority  of  cases  as 
they  are  not  as  irritating  and  are  more  readily  cleansed.  The 
discharge  through  the  tube  may  be  kept  from  coming  in  con- 
tact with  the  wound  by  employitig  a  bag  of  rubber  tissue  con- 
taining gauze,  a  strip  of  which  leads  down  into  the  glass  tube 
(Fig.  20).  The  bag  is  formed  by  making  a  minute  hole  in  the 
center  of  a  twelve-inch  square  of  rubber  dam.  This  is  snapped 
over  the  end  of  the  glass  tube  and  the  edges  of  the  rubber  sheet 
gathered  together  over  the  gauze  and  secured  by  a  tape. 

Sterilization  of  Catgut.     Alcohol  Method  (Fig.  21), — Catgut  is 


Fig.  20. — Glass  drainage 
tube  with  rubber  dam  and 
gauze  strip. 


PREPARATION    OF    INSTRUMENTS    AND    SUPPLIES 


53 


wound  evenly  on  glass  spools,  one  yard  of  catgut  on  each  spool, 
and  each  spool  placed  in  a  glycerin-jelly  jar.  Each  jar  is  then 
filled  with  absolute  alcohol,  the  cap  lightly  screwed  on,  and  the 
jars  placed,  cap  down,  in  a  two-quart  glass  jar  and  covered  with 
absolute  alcohol.  This  jar  is  then  placed  in  a  water-bath  on  a 
gas  stove  (unlighted).     A  platform  of  wire  netting,  such  as  is 


f 


Fig.  21. — -Apparatus  for  sterilizing  catgut  by  boiling  in  alcohol.  A, 
fruit  jar  containing  jelly  jars  filled  with  catgut;  B,  Dowd's  condenser;  C, 
water-bath;  D,  rubber  cork  (onnecting  the  jar  with  the  condenser;  E,  tube 
extending  from  body  of  condenser  through  which  the  condensed  vapor  of 
the  alcohol  flows  back  into  the  jar;  F,  tubing  connected  with  cold-water 
faucet;  G,  outflow  tube  for  water  from  the  condenser;  H,  cotton-sealed 
receptacle  for  overflow  of  alcohol  (should  be  placed  further  away  from  the 
flame) ;  I,  gas  stove.     (Fowler's  Surgery.) 

used  in  making  wire  splints,  is  placed  at  the  bottom  of  the  water- 
bath,  and  on  this  the  large  jar  rests.  The  top  of  the  jar  is  of 
rubber  and  should  fit  very  snugly.  Through  the  center  of  this 
top  runs  the  lower  tube  of  a  Dowd  condensing  apparatus.  The 
inlet  water  tube  of  the  condenser  is  connected  with  a  water 
tap  and  a  small  stream  of  water  turned  on.  The  outlet  water 
tube  is  led  into  the  sink.     The  end  of  the  outlet  alcohol  tube  is 


54  OPERATIXG    ROOM    AXD    THE    PATIENT 

placed  in  a  glass  jar,  the  top  of  which  is  covered  with  gauze 
wrung  out  of  bichlorid.  This  jar  should  be  set  at  a  distance 
from  the  flame  of  the  gas  stove.  Unless  a  large  jar  is  used  for 
this  purpose,  it  may  be  necessary  to  empty  it  two  or  three  times 
during  the  hour.  Enough  alcohol  to  cover  the  jelly  jars  should 
be  left  in  the  jar.  When  the  gas  stove  is  turned  out  and  the 
sterilization  jar  begins  to  cool,  this  alcohol  is  sucked  back  by 
the  vacuum  in  the  sterilizing  jar.  Care  must  be  taken  that  no 
fire  is  in  the  vicinity  of  the  alcohol  until  the  entire  apparatus  is 
set  up  and  ready  to  start.  The  catgut  is  boiled  in  alcohol  three 
successive  times  for  one  hour  at  intervals  of  twenty-four  hours. 
It  is  not  removed  from  the  sterilizer  jar  until  the  entire  apparatus 
is  cool.  Nor  is  fresh  alcohol  added  to  the  alcohol  bath,  except 
under  the  above  conditions.  Finally  the  small  j  ars  are  removed 
from  the  large  jar  and  their  caps  screwed  down  tightly.  They 
are  then  placed  in  a  large  sterile  jar  and  kept  covered  with  abso- 
lute alcohol. 

Chromic  Catgut  No.  1. — ^Plain  catgut  is  sterilized  for  one  hour 
by  the  above  method.  It  is  then  wound  from  the  spool  on  glass 
plates,  thoroughly  dried  for  twenty-four  to  forty-eight  hours  (if 
not  thoroughly  dried  the  retained  moisture  weakens  the  gut), 
subsequently  boiled  in  a  solution  of  chromic  acid,  1:5000,  for 
one  hour,  and  left  immersed  in  this  solution  for  twelve  hours. 
Following  this,  it  is  allowed  to  dry  thoroughly,  wound  again  on 
spools,  and  prepared  by  the  alcohol  method. 

Chromic  Catgut  No.  2. — Plain  catgut  is  immersed  for  twenty- 
four  hours  in  ether  and  sterilized  by  boiling  in  alcohol  for  one 
hour.  It  is  dried  for  tw^o  days  and  then  placed  for  thirty  hours 
in  a  jar  containing  the  following  solution: 

Bichromate  of  potassium gr.  iss 

Carbolic  acid gr.  x 

Glycerin 5  j 

Water O j . 

It  is  then  thoroughly  dried  and  prepared  by  the  alcohol  method. 
Braided  Catgut. — Cut  three  strands  of  catgut  No.  0  or  1  in 
twenty-inch  lengths;  knot  together  at  the  end,  then  braid. 
Sterilize  by  the  alcohol  method,  placing  two  braided  sutures 
in  each  small  jelly  jar. 


PREPARATION    OF    INSTRUMENTS    AND    SUPPLIES  55 

Bartlett  Method. — Desired  lengths  of  catgut  in  coils  held 
together  by  silk  for  convenience  in  handling  are  placed  on  a  sheet 
of  asbestos  in  a  hot-air  chamber,  the  temperature  being  gradually 
raised  in  the  first  hour  to  180°  F.,  and  the  second  hour  to  220°  F, 
It  is  then  placed  in  an  asbestos  lined  kettle  containing  liquid 
alboline  and  allowed  to  remain  there  until  it  is  perfectly  clear 
in  the  sense  that  the  term  is  used  in  the  preparation  of  histologic 
specimens.  This  process  of  clearing  is  usually  completed  in  a 
few  hours.*  It  is  not  material  how  long  the  catgut  is  allowed  to 
remain  in  the  alboline  after  the  clearing  is  established.  Upon 
the  completion  of  the  clearing  process  or  as  soon  thereafter  as 
convenient,  the  kettle  is  placed  upon  a  sand  bath  and  the  tem- 
perature gradually  raised  during  one  hour  to  320°  F.  This 
temperature  is  maintained  for  one  hour.  The  catgut  is  removed 
from  the  alboline  with  sterile  forceps  and  placed  in  a  mixture  of 
iodin  crystals,  one  part,  and  Columbian  spirits,  one  hundred 
parts.  The  silk  thread  is  removed,  yifter  twenty-four  hours 
immersion  the  gut  is  ready  for  use.  Raising  the  temperature 
too  rapidly  either  in  the  hot  air  chamber  or  while  the  gut  is 
being  treated  by  alboline  will  result  in  rendering  the  catgut 
brittle. 

Kangaroo  tendon  is  sterilized  by  boiling  for  one-half  hour  in 
alboline,  at  a  temperature  of  245°  F.,  then  transferred  to  absolute 
alcohol  in  glass  tubes  and  sealed. 

Silk  is  boiled  on  small  spools  for  five  minutes  in  normal  saline 
solution,  and  preserved  in  a  solution  of  alcohol-bichlorid  (1 :  5000) ; 
or  boiled  for  five  minutes  in  bichlorid,  1 :  500,  and  preserved  in 
the  same  solution.  This  latter  process  weakens  the  silk.  Silk 
will  usually  stand  but  three  sterilizations,  so  but  small  quantities 
should  be  made  up  at  one  time. 

Pagenstecher  thread  (linen  thread  treated  with  celluloid)  comes 
in  skeins  of  several  yards.  It  is  stronger  than  silk  of  the  same 
size,  is  sterilized  without  deterioration  by  boiling,  stands  repeated 
sterilizations,  does  not  tangle  so  readily  as  silk  as  it  is  stiffer. 
It  is  preferably  prepared  just  before  use  by  boiling  with  the 
instruments.  It  is  not  so  smooth  or  pliable  as  paraffin  silk. 
Linen  thread,  Swedish  linen  thread  are  prepared  in  the  same 
manner. 


56  OPERATIXG    ROOM    AXD    THE    PATIENT 

Paraffin  Silk. — -Wind  the  silk  loosely  on  a  glass  spool,  and 
soak  for  one-half  hour  in  soft,  white  paraffin  at  a  temperature 
not  higher  than  240°  F.  Drain  in  a  sterile  towel.  Sterilize  by 
steam  heat,  fractional  sterilization. 

Silkworm-gut. — Boil  for  ten  minutes  in  normal  salt  solution. 
Preserve  in  a  solution  of  carbolic  acid,  1:30;  or  boil  a  sufficient 
quantity  for  each  series  of  operations  with  the  instruments. 

Horsehair. — Scrub  Avith  hot  water  and  green  soap,  rinse 
thoroughly  in  plain  water,  then  in  alcohol  50  per  cent.  Boil  for 
three  minutes  in  saline  solution.  Preserve  in  alcohol-bichlorid, 
1:1000. 

Silver  Wire. — ^.Vll  small  pieces  of  silver  wire  should  be  saved, 
as  the  manufacturers  allow  for  the  silver  returned.  It  is  prepared 
hj  boiling  for  ten  minutes  in  normal  salt  solution. 

Iron  wire,  such  as  is  used  to  suspend  stove  pipe,  is  preferable 
to  silver  or  other  wire,  as  it  is  of  greater  tensile  strength  and  does 
not  break  on  twisting.     It  is  sterilized  by  boiling. 


PEECEXTAGE  TABLE. 

solu 
grs. 


To  make  four  fluid  ounces  of  solution 
1/10  of  1  per  cent,  equals  1 .  92  gr 
1/8  of  1  per  cent,  equals  2.40  grs. 
1/6  of  1  per  cent,  equals  3.20  grs, 
1/4  of  1  per  cent,  equals  4.80  grs. 
1/3  of  1  per  cent,  equals  6.40  grs. 
1/2  of  1  per  cent,  equals  9.60  grs. 

1  per  cent,  equals  19.20  grs. 

2  per  cent,  equals  38.40  grs. 

2  1,  2  per  cent,  equals  48.00  grs. 

3  per  cent,  equals  57.60  grs. 

4  per  cent,  equals  76.80  grs. 

5  per  cent,  equals  96 .  00  grs. 

6  per  cent,  equals  115.20  grs. 

7  per  cent,  equals  134.40  grs. 

8  per  cent,  equals  153.60  grs. 
10  per  cent,  equals  192.00  grs 
Other  strengths  in  proport'  — 


grs. 
ion. 


Thermocautery  (Fig.  22). — The  thermocautery  should  be 
thoroughly  tested  each  operating  day.  There  shordd  be  an 
extra  cautery  in  case  of  accident.  Its  principal  use  in  the  oper- 
ating room  -^411  be  for  the  destruction  of  mucous  membrane  in 


PREPARATION    OF    INSTRUMENTS    AND    SUPPLIES  57 

appendicectomy,  in  operations  upon  the  liver  and  bile  passages, 
and  in  hemorrhoid  operations.  All  three  cautery  tips — the 
point,  the  knife,  and  the  button — should  be  in  thorough  order. 
The  benzin  chamber  of  the  cautery  should  be  replenished  and 
the  cap  screwed  on,  and  the  rubber  tube  and  bulb  attached. 
The  tip  is  held  in  a  gas  flame  until  it  becomes  a  dull  red.  The 
benzin  vapor  is  forced  through  the  cautery  by  squeezing  the 
rubber  bulb.     Care  is  taken  not  to  fill  the  rubber  air  reservoir 


Fig.  22. — Thermocautery.  A,  Hollow  handle  containing  absorbent  cotton 
— saturated  with  benzin;  B,  removable  cap;  C,  connecting  tubing;  D, 
rubber  bulb;  E,  secondary  bulb  guarded  by  netting;  F,  alcohol  lamp  and  cap; 
G,  knife-shaped  cautery  point;  H,  pointed  cautery  point;  I,  dome-shaped 
cautery  point;  J,  extension  attachment  to  be  used  with  the  shorter  cautery 
points.      (Fowler's  Surgery.) 

too  full  or  it  may  burst.  The  benzin  vapor  must  not  be  forced 
through  until  the  cautery  tip  becomes  red.  If  this  is  done 
prematurely,  the  vapor  cools  the  tip  and  the  heating  process  has 
to  be  repeated.  Some  cauteries  are  provided  with  an  apparatus 
by  which  the  preliminary  heating  is  accomplished  through  an 
extra  tube  connecting  the  benzin  chamber,  a  stopcock  controlling 
the  flow  of  benzin.  From  three  to  five  minutes  should  be  allowed 
to  get  the  cautery  in  running  order.  Once  heated,  the  rubber 
bulb  should  only  be  pressed  sufficiently  often  to  keep  the  tip 
dull  red,  dull  red  showing  the  proper  amount  of  heat  for  cau- 
terizing. If  the  tip  becomes  too  hot,  this  is  remedied  by  mo- 
mentarily pressing  the  rubber  tube,  thus  shutting  off  the  air.    Just 


58  OPERATIXG    ROOM    AXD    THE    PATIENT 

before  the  cautery  is  handed  to  the  operator,  a  dry  sterile  tOT\-el 
should  be  thrown  around  the  bod}'  of  the  instrument  in  such  a 
manner  as  to  allow  the  operator  to  grasp  the  instrument  without 
touching  it  directly.  In  handing  the  cautery  to  the  operator 
and  in  receiving  it  from  him.  the  nurse  should  exercise  great 
care  not  to  allow  the  tube  to  touch  am-thing  sterile.  The  heated 
thermocautery  should  be  kept  at  a  distance  from  the  anesthetic. 
After  use  the  tip  should  be  thoroughly  heated  and  allowed  to  cool 
slowly.  AYhen  quite  cool,  the  tip  is  genth'  cleansed  with  gauze. 
For  appendicial  operations  the  point  tip  is  most  frequently  em- 
ployed; for  hemorrhoid  operations,  the  button  tip;  for  liver 
operations  all  three  may  prove  useful. 

Sandbags,  useful  for  maintaining  the  patient  in  the  required 
position  and  for  supporting  plaster-of-Paris  casts  while  drying, 
are  made  in  six  convenient  sizes;  25X8  inches;  18X10;  12X10; 
10X9;  12X5;  20X15.     They  are  covered  with  rubber  sheeting. 

Splints  are  kept  in  a  small  room  adjoining  the  anesthetic 
room.  All  varieties  of  splints  and  splint  material  should  be  in 
stock.  There  should  be  a  small  bench  and  set  of  tools  so  that 
special  splints  can  be  made. 

Adhesive  Plaster. — Officinal  resin  plaster,  rubber  plaster,  and 
moleskin  plaster  are  the  varieties  commonly  employed.  Sur- 
geon's adhesive  plaster — ^I'ubber  plaster — is  now  made  in  com- 
bination with  zinc  oxide,  in  order  to  render  it  less  irritating  to 
the  skin. 

Preparation. — The  plaster  may  be  used  directly  from  the  roll 
or  it  may  be  cut  in  long  strips,  one-half  to  three-fourths,  two, 
three,  or  four  inches  in  width,  and  these  strips  ma}'  be  rolled  on 
glass  or  metal  rods  six  or  eight  inches  long,  for  convenient 
handling.  The  small  strips  are  useful  for  strapping  the  ankle 
and  other  joints,  for  the  treatment  of  leg  ulcers,  and  for  retaining 
dressings;  the  Tedder  strips  for  strapping  the  chest  and  abdomen. 

Adhesive  plaster  may  be  used  in  the  form  of  taped  straps  to 
retain  an  abdominal  dressing  in  joosition  (Fig.  23).  For  this 
purpose  four  or  more  strips  are  used,  each  strip  having  a  length 
of  ten  or  twelve  inches  and  a  breadth  of  three  inches.  One  end 
of  each  strip  is  folded  on  itself,  adhesive  surfaces  together,  for  a 
distance  of  one-half  inch;  the  object  of  this  is  to  facilitate  removal. 


PREPARATION    OF    INSTRUMENTS    AND    SUPPLIES  59 

The  other  end  of  each  strip  is  folded  on  itself,  adhesive  surfaces 
together,  for  a  space  of  one  inch,  and  through  this  double  thick- 
ness a  triangular  cut  is  made  with  scissors,  and  through  the  open- 
ing a  half-inch  tape  is  passed  and  knotted.  Each  tape  should 
be  long  enough,  eight  to  ten  inches,  to  admit  of  being  tied  in  a 
bow  knot  to  its  fellow  of  the  opposite  side  over  the  abdominal 
dressing.  Two  of  these  prepared  adhesive  plaster  straps  are 
placed  on  the  skin  well  back  on  each  flank.  The  skin  should 
first  be  dried  to  insure  thorough  adhesion.      By  applying  straps 


Fig.   23. — Adhesive  plaster  strips  to  retain  abdominal  dressing. 

in  this  manner  it  is  only  necessary  to  untie  the  tapes  when 
inspecting  the  dressing.  This  does  away  with  the  unpleasant 
necessity  of  frequent  changes  of  adhesive  plaster,  and  furnishes 
a  more  economical  method  of  retaining  dressings  in  most  parts 
of  the  body.  These  strips  are  particularly  useful  in  Syme's 
amputation  and  other  foot  amputations  in  which  part  of  the 
tarsus  is  left.  All  adhesive  plaster  strips  should  be  scrupulously 
freed  from  ravelings.  It  is  particularly  these  threads  which 
tend  to  irritate  the  skin. 

Adhesive  plaster  may  be  employed  for  the  purpose  of  approxi- 
mating the  edges  of  a  wound.  When  so  used  the  plaster  should 
be  sterilized  by  heat,  unless  it  has  been  specifically  prepared 
for  this  purpose  by  a  reliable  manufacturer.  If  it  has  not  been 
so  prepared  it  may  be  readily  sterilized  by  passing  it  through  a 
flame.  In  applying  plaster  to  approximate  wound  edges,  space 
should  be  left  between  the  strips  to  provide  for  the  escape  of  any 


60 


OFERATIXG    ROOM    AXD    THE    PATIEXT 


discharge  that  may  form.  If  the  ends  be  turned  under  for  a 
distance  of  a  quarter  of  an  inch  or  so,  and  the  surfaces  stuck 
together,  the  strips  can  be  the  more  reachly  raised  and  with  less 
annoyance  to  the  patient  than  if  the  ends  be  directly  applied 
to  the  skin. 

Resin  plaster,  when  used  for  any  purpose,  must  be  heated  in 
order  to  make  it  adhere.  When  this  form  of  plaster  is  used,  the 
degree  of  heat  which  it  may  have  absorbed  should  be  tested  by 
applying  the  reverse  side  of  the  plaster  to  the  back  of  the  opera- 
tor's hand  before  the  plaster  is  placed  on  the  patient's  skin; 
otherwise  blistering  may  result  from  the  application  of  too  great 
heat. 

It  is  not  necessary  to  heat  rubber  plaster  to  cause  it  to  adhere, 
although  it  may  be  heated  for  purposes  of  sterilization.     Strips 


Fig.  2-4. — Stirrup  of  adhesive  plaster  to  prevent  tlie  foot  fruiu  assuming 
tlie  eqtiinus  position.  A,  A,  Padded  foot-piece;  B,  B,  adhesive  plaster  straps; 
C,  C,  bandages  securing  foot-pieces  in  position:  D,  D.  bandages  securing 
upper  ends  of  adhesive  plaster  straps.     (Fowler's  Surgerj-.) 


of  plaster  may  be  used  for  securing  dressings  in  place  while  the 
bandage  is  being  applied,  as  in  applpng  dressings  and  bandages 
to  a  circular  part  such  as  the  thigh. 

Adhesive  plaster  may  be  incorporated  in  a  bandage  in  such  a 
manner  as  to  retain  the  bandage  in  position,  part  of  the  adhesive 
plaster  being  adherent  to  the  skin  and  part  to  the  bandage. 
Adhesive  plaster  is  also  usefid  for  exercising  direct  pressure 
upon  a  part  as  in  strapping  a  joint  or  strapping  the  testicle;  for 
exerting  indirect  pressure  as  in  retaining  a  graduated  compress 
in  position:  for  securing  immobilization  in  fractures;  for  pre- 


PREPARATION    OF    INSTRUMENTS    AND    SUPPLIES  61 

venting  the  development  of  deformities,  as  in  the  prevention  of 
the  equinus  position  of  the  foot  in  patients  long  confined  to  bed, 
(Fig.  24);  for  relieving  hyperemia  as  in  the  ambulatory  treatment 
of  ulcer  of  the  leg  (Fig.  153);  for  making  extension,  (Fig.  25);  for 
preventing  inversion  of  the  lips  of  a  deep  wound,  as  in  stout 
patients  in  whom  there  has  been  fat  necrosis  in  the  wound. 

In  applying  plaster  to  any  part  of  the  body  the  parts  should 
first  be  cleansed  and,  if  necessary,  shaved.  If  it  becomes  neces- 
sary to  apply  a  second  strapping  to  a  part,  the  plaster  should, 
if  possible,  be  made  to  avoid  any  irritated  areas  that  have  resulted 
from  the  first  strapping.     Alcohol  or  benzin  will  faciliate  the 


Fig.  25. — Extension   with   adhesive   plaster.      (Fowler's  Surgery.) 

removal  of  ordinary  plaster,  Benzin  is  an  excellent  solvent  for 
plaster  and  may  also  be  used  for  cleansing  the  skin  after  the 
removal  of  the  plaster.  With  zinc-oxid  plaster  it  is  not  usually 
necessary  to  use  either  alcohol  or  benzin.  When  the  plaster  is 
removed  it  is  less  painful  to  the  patient  if,  after  the  plaster  has 
been  started,  the  skin  is  pulled  away  from  it  with  one  hand  while 
steady  traction  is  made  on  the  plaster  with  the  other  hand. 
If  the  plaster  is  pulled  away  from  the  skin  too  rapidly  and 
without  the  above  precaution  the  edges  of  the  plaster,  where 
it  has  become  most  adherent  to  the  skin,  are  apt  to  pull  away 
some  of  the  superficial  layers  of  the  skin,  and  in  some  instances 
an  injury  resembling  a  "scratch"  results. 

Adhesive  Plaster  Abdominal  Scultetus  (Fig.  26). — ^This  form 
of  dressing  was  advocated  by  Boldt  as  a  means  of  supporting 
the  abdominal  wall  after  laparotomy  and  thus  allows  of  the 
earlier  moving  about  of  the  patient.  Zinc-oxid  plaster  is  used 
to  reduce  skin  irritation  to  a  minimum.  The  quality  of  the 
plaster   should   be    such    as   to    preclude   stretching.     The.  full 


62 


OPERATING    ROOM    AND    THE    PATIENT 


■u'idth  of  tlie  plaster  (twelve  inches)  is  used  and,  according  to  the 
size  of  the  patient,  the  strip  should  measure  from  twenty-eight 
to  forty  inches  or  more  in  length.  From  the  center  of  the  lower 
edge  of  the  strip  a  semicircular  piece  is  cut,  in  order  to  avoid 
soiling  dining  defecation.  The  patient  is  placed  upon  the 
bandage  so  that  the  lower  border  comes  on  a  level  with  the  pubes. 
The  fabric  covering  the  plaster  is  now  removed.  This  is  facili- 
tated by  rolling  the  patient  first  to  one  side  and  then  to  the  other, 
while  an  assistant  steadies  the  plaster  and  removes  the  fabric. 
Each  end  of  the  plaster  is  next  split  into  four  tails.  These 
tails  are  snugly  adjusted,  the  lower  one  on  one  side  being  ap- 
plied first,  then  the  lower  one  on  the  other  side,  and  so  on. 


___  L . 

Fig.  26. — Adhesive  plaster  scxiltetus. 


These  overlap,  thus  making  a  double  support  in  front  and  at  the 
sides.  This  process  is  continued  until  the  four  tails  on  each 
side  have  been  snugly  adjusted.  If  the  upper  part  of  the 
bandage  should  reach  to  the  epigastrium,  the  upper  tails  are  not 
drawn  so  tight  to  avoid  pressure  on  the  ribs  and  consequent 
interference  with  respiration.  The  anterior-superior  spines  of 
the  ilia  are  protected  by  lightly  padding  with  gauze.  At  the 
time  for  the  removal  of  the  sutures  the  adhesive  plaster  is  cut 
in  the  middle  line  anteriorly  from  the  pubes  up  and  each  lateral 
portion  is  folded  back.  After  the  completion  of  the  dressing  the 
cut  edges  of  the  adhesive  plaster  are  reinforced  with  other  pieces 


BANDAGING  63 

of  plaster;  perforations  are  then  made  one-half  inch  from  the  cut 
edge  and  at  one-inch  intervals.  Beginning  at  the  pubes  the 
dressing  is  snugly  laced  up  with  a  piece  of  tape  or  corset  lacing 
and  the  outer  binder  applied. 


CHAPTER  III. 
BANDAGING. 


Materials. — ^According  to  the  purpose  which  they  are  to  serve, 
bandages  are  made  of  various  materials,  those  commonly  em- 
ployed being  bleached  and  unbleached  muslin,  linen,  crinoline, 
gauze,  flannel  and  rubber. 

Uses. — Bandages  are  used  for  retaining  dressings,  as  in  the 
case  of  wounds;  for  retaining  splints,  as  in  fractures;  for  making 
pressure,  as  in  the  palliative  treatment  of  varicose  veins  and  as 
in  Bier's  hyperemia  treatment  of  tuberculous  joints  and  other 
infections,  and  for  the  arrest  of  hemorrhage;  for  purposes  of 
immobilization,  as  in  fractures,  in  which  event  a  hardening  agent 
such  as  plaster  of  Paris,  paraffin,  water-glass,  or  starch  is  worked 
into  the  bandage. 

Classification. — Bandages  are  classified  according  to  the  ma- 
terials of  which  they  are  made,  according  to  the  form  in  which  the 
material  is  made  up,  and  according  to  the  purpose  for  which  the 
bandage  is  to  be  used.     Bandages  may  be  classified  as  follows: 

1.  The  simple  or  roller  bandage,  which  may  be  a  single  or 
doable  roller.  A  double  roller  is  made  by  sewing  together  the 
initial  extremities  of  two  roller  bandages  (Fig.  47).  It  is  much 
less  used  than  formerly. 

2.  Compound  bandages,  or  many-tailed  bandages  and  slings. 

3.  Immobilizing  bandages,  such  as  those  made  of  crinoline 
or  other  large-meshed  material  in  which  plaster  of  Paris  or  starch 
or  some  other  hardening  agent  has  been  incorporated.  These 
are  most  frequently  of  the  roller-bandage  type. 

4.  Pressure  bandages,  usually  made  of  rubber,  such  as  Martin's 
rubber  bandage. 

Manufacture. — Of  whatever  material  the  bandage  is  com- 
posed, the  most  frequently  used  is  the  roller  bandage.     These 


64 


OPERATING    ROOM    AXD    THE    PATIENT 


are  made  by  cutting  the  selected  material  into  strips  that  vary 
in  width  and  length,  according  to  the  locality  to  be  bandaged. 
If  gauze  is  the  material  of  which  the  bandage  is  to  be  made,  a 
simple   way   of   cutting   the   bandage   straight,   without   frayed 


Fig.  27. — Rolling  bandage  by  hand.      (Fowler's  Surgery.) 

edges,  is  to  draw  a  thread  the  desired  length  of  the  bandage,  thus 
allowing  of  the  clean  cutting  of  the  material  along  the  line  so 
indicated.  The  strips  are  rolled  into  a  cylinder  either  by  hand 
or  by  means  of  a  bandage  machine.  If  they  are  rolled  by  hand, 
one  end  of  the  strip  is  first  folded  on  itself  a  number  of  times 
until  a  smooth  cylinder  is  formed.     This  cylinder  is  grasped  by 


Fig.  28. — Hand  roller-bandage  machine.      (Fowler's  Surgery.) 

the  right  hand,  the  forefinger  pressing  u23on  one  end,  the  thumb 
on  the  other,  and  while  so  held  it  is  revolved  by  the  fingers  of  the 
other  hand  in  such  a  manner  as  to  roll  around  it  the  rest  of  the 
strip  which  is  guided  by  the  left  hand  (Fig.  27),  or,  the  bandage 


BANDAGING 


65 


having  been  started  In  the  above  manner,  the  process  may  be 
continued  by  rolling  it  on  a  hard  surface  with  the  palm  of  the 
hand,  or  by  placing  the  bandage  on  the  anterior  surface  of  the 
thigh  and  rolling  it  toward  the  knee  with  the  palm  of  the  hand. 
In  either  case  tension  should  be  made  on  the  strip  at  the  same 
time  and  care  taken  that  with  each  revolution  the  strip  accurately 
overlies  the  preceding  one.  Bandages  may  be  rolled  by  a 
machine  worked  by  hand  (Fig.  28)  or  by  foot  (Fig.  29) .  One 
end  of  the  bandage  is  fastened  under  tension  to  the  revolving 


Fig.  29. — ^Foot  roller-bandage  machine.      (Fowler's  Surgery.) 


spindle  of  the  machine,  and  this  being  turned  by  a  crank,  rapidly 
rolls  up  the  strip.  Bandages  may  be  made  rapidly  in  quantities 
in  the  following  manner:  A  wide  box,  one  foot  deep,  three  feet 
wide,  and  long  enough  to  accommodate  the  bolt  of  material,  is 
required.  This  box  (Fig.  30)  is  fitted  with  one-half  dozen 
wooden  rollers  for  guiding  the  material,  and  a  metal  roller  with  a 
crank  attached,  on  which  to  wind  the  material.  The  required 
number  of  yards  is  wound  on  the  metal  roller,  and  the  rnaterial  is 

5 


66 


OPERATING    ROOM    AND    THE    PATIENT 


cut  across.  The  roll  is  removed  by  withdrawing  the  metal  roller. 
This  long  roll  is  then  cut  into  the  required  widths  by  means  of  a 
bandage  knife.     A  Christy  bread  knife  answered  this  purpose 


Fig.  30. — Roller-bandage  box. 

admirably.     For  steadying  the  roll  while  it  is  being  cut  a  car- 
penter's small  mitre  box  is  useful  (Fig.  31). 

Dimensions. — ^The  following   are   the   most    commonl}-   used 


Fig.  31. — Mitre  box  and  Christy  knife  for  cutting  bandages. 

bandages,  though  other  materials  and  other  dimensions  are  used 
according  to  the  part  to  which  the  bandage  is  to  be  applied,  and 
also  according  to  the  purpose  for  which  it  is  to  be  used. 


BANDAGING  67 

Muslin,  7  yards  long  by  1  3/4,  2  1/2,  3,  and  4  inches  wide; 
gauze,  8  yards  long,  by  3  and  3  1/2  inches  wide;  flannel,  6  yards 
long  by  1  1/2,  2,  2  1/2,  3,  and  4  inches  wide;  crinoline,  6  yards 
long  by  2,  2  1/2,  3  1/2  and  4  inches  wide;  finger  bandages,  4 
yards  long  by  1/2  and  3/4  inch  Avide;  double  roller  head  bandage, 
10  yards  long  by  1  1/2  and  2  inches  wide;  chest  or  abdominal 
roller  bandage,  10  yards  long  by  4,  6  and  8  inches  wide;  plaster 
bandages,  7  yards  long  by  2  1/2  and  3  1/2  inches  wide;  starch 
bandages,  1,  2,  and  3  inches  wide. 

Certain  terms  are  applied  to  different  parts  of  the  roller 
bandage  in  order  to  facilitate  the  description  of  its  application. 
The  free  end  is  known  as  the  initial  extremity,  the  enclosed  end 
as  the  terminal  extremity,  and  all  the  portion  between  is  termed 
the  body  of  the  bandage.  The  surfaces  are  known  as  the 
internal  and  external. 

General  Rules. — In  the  application  of  the  roller  bandage  the 
roller  should  be  grasped  tightly  between  the  thumb  and  finger, 
the  body  of  the  bandage  resting  in  the  holloAV  of  the  hand,  the 
loose  end  on  the  palm,  so  that  it  will  unroll  easily  while  resting 
in  the  palm.  The  internal  surface  becomes  the  external  when 
it  is  applied  to  the  part,  and  the  external  surface  becomes  the 
internal.  When  a  bandage  is  applied  to  an  extremity,  it  should 
(when  applied  anteriorly)  roll  away  from  the  median  line  of  the 
body.  The  turns  are  always  to  be  applied  smoothly  and  with 
even  pressure;  otherwise,  swelling  or  even  gangrene  may  result. 
If  it  is  too  tightly  applied,  though  with  even  pressure,  ischemic 
muscular  paralysis  may  result.  In  the  case  of  an  extremity 
the  bandage  should  be  begun  at  the  toes  or  fingers  and  applied 
in  an  upward  direction.  Before  the  application  of  the  bandage 
the  part  to  be  bandaged  should  be  placed  in  the  position 
in  which  it  is  to  remain  after  the  bandage  is  applied.  If 
this  is  not  done  the  bandage  will  n^t  lie  smoothly  and  may 
subsequently  cause  uneven  pressure.  When  bleached-muslin 
bandages  are  employed,  the  material  may  be  wrung  out  of 
warm  water,  as  this  will  be  found  to  facilitate  the  application, 
particularly  in  the  case  of  small  muslin  bandages,  such  as  finger 
bandages.  The  terminal  extremity  should  be  fastened,  either 
by  sewing  with  needle  and  thread  or  by  the  use  of  safety-pins, 


68  OPERATIXG    ROOM    AXD    THE    PATIEXT 

or  the  end  may  be  torn  longitudinally,  knotted  to  prevent 
further  tearing,  and  the  two  tails  passed  around  the  part  in 
opposite  directions  and  tied.  When  pelvic  or  chest  bandages 
are  applied,  the  body  may  be  supported  by  the  Yolkmann 
block  (Fig.  32).  An  inverted  hand  basin  serves  the  purpose 
in  an  emergency. 


Fig.   32. — Volkmann's  block.      (Fowler's  Surgen'.) 

Bandages  are  removed  either  by  cutting  or  by  unwinding 
them.  If  they  are  removed  by  cutting,  special  scissors  having 
a  blunt  point  on  one  blade  should  be  used  in  order  to  prevent 
possible  injury  to  the  skin  (Fig.  33).  If  a  bandage  is  removed 
by  unAvinding  it,  the  unrolled  portion  should  be  loosely  grasped 
in  a  mass  as  the  unwinding  proceeds,  the  unwound .  portion 
being  passed  from  one  hand  to  the  other,  thus  allowing  of  rapid 
and  neat  removal.     In  hospital  practice  bandages  should  be 


Fig.  33. — Bandagie  scissors.      (Fowler's  Surgery.) 

removed  by  unrolling  rather  than  by  cutting,  unless  they  are 
too  soiled  to  allow  of  ready  cleansing,  or  unless  their  removal 
by  unrolling  would  cause  pain  to  the  patient  by  undue  moving 
of  the  affected  part. 

Varieties   of  Roller  Bandages. — In  bandaging,   a  number  of 


BANDAGING 


69 


turns  are  used  with  which  it  is  necessary  to  become  familiar 
before  applying  any  special  bandage.  Circular,  spiral,  and 
spica  turns  are  used  either  alone  or  in  combination,  or  with 
some  modifications,  and  the  bandage,  the  predominating  feature 


I'ig.  34. — Circular  bandage.     (Fowler's  Surgery.) 

of  which  is  formed  by  these  turns  is  known  as  a  circular,  spica, 
or  spiral  bandage. 

Circular  Bandage. — A  circular  bandage  (Fig.  34)  is  made  up 
of  a  number  of  circular  turns,  each  turn  overlying  the  turn 
preceding  it.  It  is  useful  in  retaining  dressings  upon  circular 
portions  of  the  body,  and  for  purposes  of  coaptation. 


Fig.  35. — Esmarch's  bandage  applied.  Showing  method  of  application 
without  overlapping.  The  last  three  turns  serve  as  a  tourniquet.  (Fowler's 
Surgery.) 

Oblique  Bandage. — An  oblique  bandage  is  one  in  which  the 
turns  run  obliquely  around  the  part  without  overlapping  (Fig. 
35).  Such  a  bandage  is  useful  in  applying  temporary  dressings. 
The  Esmarch  bandage  is  applied  in  this  manner,  to  allow  of 
ready  removal  in  the  reverse  order  of  that  which  was  employed 
when  it  was  originally  applied. 


70 


OPERATING  ROOM  AND  THE  PATIENT 


Spiral  Bandage. — In  a  spiral  bandage  (Fig.  36),  the  turns 
surround  the  part  in  a  spiral  manner,  each  turn  covering  one- 
half  or  more  of  the  preceding  turn.     This  form  of  bandage  is 


rig.  36. — Spiral  bandage.      (Fowler's  Surgery.) 

useful  in  parts  of  the  body  which  do  not  increase  rapidly  in 
circumference,  as  the  finger,  chest,  or  abdomen. 

Reversed  Spiral  Bandage. — When  the  part  of  the  body  to  be 
bandaged   increases   rapidly   in   circumference,    as    in   the    case 


Fig.  37. — The  spiral  reversed  bandage.      (Fowler's  Surgery.) 

of  the  forearm  or  leg  of  a  well-nourished  person,  it  is  found 
impracticable  to  use  spiral  turns,  as  they  do  not  lie  smoothly  and, 
what  is  more  important,  do  not  exert  even  pressure.  To  over- 
come this,  when  a  part  of  the  limb  is  reached  where  the  spiral 


BANDAGING 


71 


turn  if  continued  would  not  lie  smoothly,  a  "reverse"  is  made 
so  as  to  cause  the  turn  to  conform  to  the  shape  of  the  part 
(Fig.  37).  In  making  these  reverses  it  is  well  not  to  unroll  much 
of  the  bandage,  but  only  six  or  eight  inches  of  it.  While  the 
forefinger  of  the  left  hand  presses  on  the  previously  applied  turn 
and  holds  it  in  place,  the  head  of  the  roller  is  turned  toward  the 
operator  in  such  a  manner 
that  the  slack  is  turned  or 
folded  obliquely  on  itself.  As 
many  of  these  reverse  turns 


Fig.  38. — Short  figure-of-S  (spica)         Fig.  39. 
bandage  of  the  leg. 


-Long  figure-of-8  bandage 
of  the  leg. 


are  applied  as  are  required.  Care  must  be  taken  that  the  points 
of  the  reverses  are  in  alignment,  that  they  are  smoothly  applied, 
and  that  they  do  not  lie  over  bony  prominences,  such  as  the 
crest  of  the  tibia,  for  here  they  may  give  rise  to  pressure  effects. 

Spica  Bandage. — Spica  turns  are  those  which  cross  each  other 
in  the  form  of  the  capital  Greek  letter  Lambda,  and  a  bandage 
made  up  for  the  most  part  of  these  turns  is  known  as  a  spica 


72 


OPERATING  ROOM  AND  THE  PATIENT 


bandage  (Fig.  38).  Such  a  bandage  is  useful  in  retaining  dress- 
ings to  the  shoulder  and  groin,  and  also  in  exerting  firm  pressure. 
Figure-of-8  Bandage. — ^Those  bandages  are  made  of  figure-of-8 
turns,  and  are  most  frequently  employed  in  the  neighborhood  of 
joints,  a  turn  being  first  taken  above  the  joint  and  then  one  below 
it,  thus  forming  a  figure-of-8.  In  the  same  manner  a  figure-of-8 
may  be  applied  to  the  leg,  either  short  turns  being  used,  when 

the  bandage  is  known  as  a  short 
figure-of-8  or  spica  (Fig.  38),  or  longer 
ones  with  some  spiral  turns,  when  it  is 
known  as  a  long  figure-of-8  (Fig.  39). 
Recurrent  Bandage. — Recurrent 
bandages  (Fig.  40)  are  made  up  of 
turns  which  extend  back  and  forth 
over  the  part  until  it  is  covered  in, 
all  these  turns  being  secured  by  spiral 
or  circular  turns.  This  bandage  is 
used  for  covering  in  the  ends  of 
fingers,  for  retaining  stump  dressings, 
and  for  retaining  dressings  upon  the 
scalp. 

Head  Bandages :  Fronto -occipital 
Bandage. — ^The  initial  extremity  of 
the  bandage  (Fig.  41)  is  fixed  beneath 
the  inion  by  means  of  the  index- 
finger  of  the  left  hand;  the  roller  is 
then  carried  across  the  parietal  bone 
of  the  left  side  to  the  forehead,  over  the  forehead,  and  over  the 
right  parietal  region  back  to  the  starting-point ;  these  turns  are 
repeated,  care  being  taken  that  each  turn  shall  accurately  cover 
the  preceding  turn.  The  terminal  extremity  of  the  bandage  is 
fastened  beneath  the  inion. 

Oblique  Bandage  of  the  Head. — ^The  initial  extremity  of  this 
bandage  (Fig.  42)  is  fixed  by  means  of  one  or  two  fronto-occipi- 
tal  turns.  From  the  occiput  the  roller  is  passed  obliquely  over 
the  left  parietal  eminence  to  the- forehead  and  then  continued  as 
in  making  a  fronto-occipital  turn,  that  ends  at  the  forehead. 
From  the  forehead  the  roller  passes  obliquely  over  the  right 


Fig.  40. — Recurrent  band- 
age of  stump.  (Fowler's 
Surgery.) 


BANDAGING  73 

parietal  eminence  to  the  occiput.  At  the  occiput  these  turns 
are  continued  in  the  order  named,  each  oblique  turn  covering  in 
the  lower  two-thirds  of  the  preceding  oblique  turn.  The  bandage 
is  completed  by  one  or  more  fronto-occipital  turns,  the  terminal 
extremity  being  fastened  beneath  the  inion.  These  oblique 
turns  make  a  very  pretty  finish  to  a  recurrent  head  bandage,  and 
at  the  same  time  render  it  more  secure. 


Fig.  41. — Fronto-occipital  bandage.       Fig.  42. — Oblique  bandage  of  the 
(Fowler's  Surgery.)  head.      (Fowler's  Surgery.) 

Recurrent  Bandage  of  the  Head. — The  initial  extremity  of  the 
bandage  (Fig.  43)  is  secured  by  means  of  one  or  two  fronto- 
occipital  turns.  Beginning  at  the  central  point  of  the  forehead 
a  reverse  is  made  and  the  roller  carried  directly  back  to  the  me- 
dian line  over  the  vertex  to  just  below  the  inion;  here  the  roller 
is  folded  on  itself  and  carried  forward  to  the  forehead,  to  the  left 
of  the  first  recurrent  turn,  so  that  it  overlaps  it  by  two-thirds. 
These  recurrent  turns  are  repeated  between  the  occiput  and  the 
forehead  until  the  whole  of  the  left  Half  of  the  vertex  is  covered. 
The  recurrent  turns  are  then  secured  by  a  fronto-occipital  turn. 
In  the  same  manner  the  right  half  of  the  vertex  is  covered  in. 
The  bandage  is  completed  by  one  or  more  fronto-occipital  turns. 


74  OPERATING  ROOM  AXD  THE  PATIEXT 

Barton's  Bandage. — ^The  initial  extremity  of  the  bandage 
(Fig.  44)  is  fixed  to  the  vertex  of  the  head  in  the  middle  line, 
the  index-finger  of  the  left  hand  being  used  for  the  purpose. 
The  roller  is  then  passed  over  the  left  parietal  bone  to  a  point 
below  the  inion.  and  then  over  the  right  parietal  bone  to  the 
starting-point;  this  forms  turn  number  1.  To  form  turn  number 
2,  the  roller  is  continued  from  the  starting-point  over  the  tem- 
poral bone,  down  the  side  of  the  left  cheek,  in  front  of  the  left 


Fig.  43. — Recurrent  bandage  of  the  head.      (,Fowler's  Surgery.) 

ear,  under  the  chin,  up  the  side  of  the  right  cheek,  in  front  of  the 
right  ear,  and  finally  over  the  right  temporal  bene  to  the  starting- 
point.  To  form  turn  number  3,  continue  from  the  starting- 
point  over  the  left  parietal  bone  to  a  point  below  the  inion,  be- 
low the  right  ear,  around  the  right  side  of  the  inferior  maxilla, 
to  the  front  of  the  chin,  passing  over  the  anterior  aspect  of  the 
chin  to  the  left  aspect  of  the  inferior  maxilla,  and  then  over  this 
and  below  the  left  ear  to  a  point  just  below  the  inion.  These 
three  turns  are  repeated  a  number  of  times  in  the  order  described. 
The  bandage  has  been  modified  by  adding  (Fig.  45)  a  fourth 
turn — a  fronto-occipital  turn  following  the  third  turn.     Except 


BANDAGING 


75 


for  this  the  modified  Barton's  is  the  same  as  the  Barton's  usually 
described.  The  points  of  intersection  of  the  various  turns  are 
secured  by  safety-pins.  In  applying  this  bandage,  as  in  apply- 
ing all  bandages  which  fix  the  lower  jaw,  care  should  be  taken, 
Avhen  the  application  is  made  under  an  anesthetic,  that  provision 
is  allowed  for  the  escape  of  vomited  matter. 


Fig.  44. — Barton's  bandage. 
(Fowler's  Surgery.) 


Fig.  45. — Modified  Barton's  bandage. 
(Fowler's  Surgery.) 


Gibson's  Bandage. — The  initial  extremity  of  the  bandage 
(Fig.  46)  is  fixed  with  the  forefinger  of  the  left  hand  over  the 
temporal  region  just  anterior  to  the  left  ear;  thence  the  roller 
is  carried  down  the  cheek,  under  the  chin,  up  in  front  of  the 
right  ear,  and  over  the  vertex  to  its  starting-point.  Three  such 
complete  turns  are  made.  A  reverse  is  made  at. the  end  of  the 
third  turn  and  the  roller  is  carried  to  the  inion,  and  three  com- 
plete fronto-occipital  turns  ending  at  the  inion  are  made.  The 
roller  is  then  carried  around  under  the  right  ear,  along  the  jaw 
to  the  chin,  over  the  front  of  the  chin,  along  the  left  side  of  the 
jaw,  and  under  the  left  ear  to  the  inion.  Three  such  complete 
turns  ending  at  the  inion  are  made.     Here  the  roller  is  reversed 


76 


OPERATIXG    ROOM    AND    THE    PATIEXT 


and  carried  in  the  median  line  from  the  vertex  to  the  forehead, 
where  it  is  fastened.  All  intersections  of  turns  are  secured  by 
means  of  safety-pins. 

A  similar  way  of  applying  the  turns,  and  one  which  is  perhaps 
more  secure,  is  to  fix  the  initial  extremity  of  the  bandage  at  the 
verteix,  and  then  to  pass  clown  the  right  side  of  the  jaw  in  front  of 
the  ear  to  the  chin,  under  the  chin,  up  the  left  side  of  the  jaw, 


Fig.  46. — Gibson's    bandage.     Safety-pins    should    be  placed   on  all   the 
intersections  to  prevent  the  bandage  from   shpping.      (Fowler's   Surgery.) 

in  front  of  the  ear,  and  so  back  to  the  vertex,  where  the  initial 
extremity  of  the  bandage  is  crossed  by  the  roller,  and  the  roller 
continued  over  the  right  parietal  bone  to  the  inion,  under  the 
inion,  and  up  over  the  left  parietal  bone  to  the  starting-point, 
thus  making  a  figure-of-8  turn.  This  figure-of-8  turn  is  repeated 
three  or  four  times,  and  then  when  the  inion  is  again  reached,  on 
the  third  or  fourth  turn,  the  third  turn  of  the  Gibson  bandage  as 
before  described  is  made. 

Crossed  Bandage  of  the  Head. — A  double-headed  roller  is 
used.  A  fronto-occipital  turn  is  made,  the  bandage  "crossing" 
just  above  the  temporo-maxillary  articulation  (Fig.  47).     The 


BANDAGING 


77 


roller  is  carried  down  over  the  side  of  the  jaw,  under  the  chin, 
and  up  the  opposite  side  of  the  jaw  to  the  temporo-maxillary 
articulation  of  that  side.  Here  it  is  "crossed"  by  the  other 
roller,  which  is  passed  over  the  vertex  (Fig.  48).  The  points  of 
"crossing"  alternate. 

Occipito -facial  Bandage. — This  bandage  is  applied  in  the  same 
manner  as  the  first  and  second  turns  of  the  Gibson  bandage,  by 
either  of  the  methods  just  described  The  turns  along  the  side 
of  the  jaw,  however,  cover  in  more  of  the  surface  and  do  not 
accurately  overlie  each  other. 


Fig.  47. — Crossed  bandage  of  the 
head.     First  turn. 


Fig.  48. — Crossed  bandage  of  the 
head.     Second  turn. 


Forehead  and  Chin  Bandage  (Fig.  49) . — The  initial  extremity  of 
the  bandage  is  fixed  by  one  or  two  fronto-occipital  turns.  From 
below  the  inion  the  roller  is  passed  around  the  side  of  the  jaw, 
below  the  ear  to  the  chin,  across  the  anterior  surface  of  the  chin 
and  along  the  left  side  of  the  jaw,  below  the  left  ear,  to  a  point 
below  the  inion.  A  fronto-occipital  turn  is  then  made.  These 
turns  are  alternated. 

The  Forehead  and  Upper  Lip  Bandage. — This  bandage  (Fig.  50) 
is  applied  in  the  same  manner,  except  that  the  second  turn  passes 


78 


OPERATING    ROOM    AND    THE  "PATIENT 


from  the  inion  to  a  point  above  the  ear,  thence  to  the  upper  lip, 
and  so  around  above  the  opposite  ear  to  the  inion. 

In  the  forehead  and  neck  bandage  the  second  turn  passes  from 
the  inion,  around  the  neck,  and  back  to  the  inion. 

Oblique  Bandage  of  the  Jaw. — The  initial  extremity  of  this 
bandage  (Fig.  51)  is  fixed  by  means  of  one  or  more  fronto-oc- 
cipital  turns.  If  it  is  intended  to  cover  in  the  left  side  of  the  jaw 
the  roller  is  passed  from  right  to  left;  if  the  right  side,  from  left 
to  right.     From  the  occiput  the  roller  is  passed  below  the  ear, 


Fig.  49. — -i^orehead  and  chin  band- 
age.     (Fowler's  Surgery.) 


Fig.  50. — Forehead  and  upper  hp 
bandage.      (Fowler's  Surgery.) 


under  the  chin,  and  up  over  the  opposite  angle  of  the  jaw.  It  is 
then  carried  to  the  vertex  from  the  side  of  the  face  just  posterior 
to  the  external  angular  process  of  the  frontal  bone,  and  in  front 
of  the  ear  of  the  same  side.  The  roller  is  carried  across  the  vertex, 
behind  the  ear  of  the  opposite  side,  to  the  point  at  which  it  first 
passed  under  the  chin;  thence  it  is  continued  around  under  the 
chin  as  before,  this  time,  however,  the  turn  being  so  placed  as  to 
overlap  the  posterior  two-thirds  of  the  previous  turn.  These 
turns  are  continued,  each  overlapping  the  posterior  two-thirds  of 


BANDAGING 


79 


the  previous  turn  until  the  space  between  the  external  angular 
process  and  the  ear  is  completely  covered.  The  oblique  turns 
may  include  the  ear  if  the  indication  for  this  is  present.  When  a 
sufficient  number  of  these  turns  have  been  applied,  a  reverse  is 
made  above  the  opposite  ear,  two  or  three  f ronto-occipital  turns 
are  made,  and  the  bandage  is  secured. 

Single  Eye  Bandage. — The  initial  extremity  of  the  bandage 
(Fig.  52)  is  fixed  by  one  or  two  fronto-occipital  turns.  If  it  is 
desired  to  cover  in  the  left  eye  the  turns  should  pass  from  right  to 


Fig.   51. — <  )l)li(iU('  haudiigo  ui  the  jiiw 


Surgery.) 


left;  if  the  right  eye,  vice  versa.  From  the  occiput  the  roller  is 
passed  below  the  lobe  of  the  ear  to  the  cheek,  upward  over  the 
cheek  to  the  glabella,  thence  obliquely  over  the  frontal  and 
parietal  regions  of  the  opposite  side  to  the  occiput,  forming 
turn  number  one;  a  fronto-occipital  turn  is  then  made.  Turn 
number  two  is  the  same  as  turn  number  one,  save  that  it  ascends 
above  it  by  one-third  its  width.  It  will  be  found  more  comfort- 
able for  the  patient  if  the  second  and  subsequent  turns  cover  in 
the  ear  instead  of  passing  below  it,  as  in  the  case  of  the  first 


80 


OPERATING    ROOM    AND    THE    PATIEXT 


turn.  These  turns  are  repeated,  alternating  with  the  front o- 
occipital  turns,  until  the  eye  is  entirely  covered  in.  A  few 
fronto-occipital  turns  complete  the  bandage. 

Bandage  for  Both  Eyes. — The  initial  extremity  of  the  bandage 
(Fig.  53)  is  fixed  by  one  or  more  fronto-occipital  turns.  From 
the  occiput  the  roller  is  passed  under  the  lobe  of  one  ear  to  the 
cheek,  upward  upon  the  cheek  to  the  glabella,  covering  in  the 
first  eye,  and  thence  obliquely  across  the  opposite  frontal  and 


Fig.  52. — Single  eye  bandage. 
(Fowler's  Surgery.) 


Fig.  53. — Bandage  for  both  eyes. 
(Fowler's  Surgery.) 


parietal  regions  to  the  occiput.  A  fronto-occipital  turn  is  then 
made.  From  the  occiput  the  roller  is  passed  up  over  the  parietal 
and  frontal  regions  to  the  glabella,  thence,  over  the  second  eye, 
obliquely  down  the  cheek,  beneath  the  lobe  of  the  ear,  to  the 
occiput.  Again  a  fronto-occipital  turn  is  made.  These  turns 
are  repeated  first  over  one  eye  and  then  over  the  other  eye, 
each  succeeding  turn  covering  in  tvvo-thirds  of  the  preceding 
turn,  and  being  alternated  by  a  fronto-occipital  turn.  These 
turns  are  continued  until  the  eyes  are  completely  covered.  The 
fronto-occipital  turn  may  be  omitted. 

Figure-of-S   Bandage    of   the   Neck   and   Axilla. — ^The   initial 
extremity  of  the  bandage  (Fig.  54)  is  fixed  bv  one  or  more  circular 


BANDAGING 


81 


turns  around  the  neck;  these  should  not  be  too  tightly  applied. 
According  to  the  axilla  to  be  included,  the  roller  is  passed  ob- 
liquely across  the  corresponding  shoulder,  under  the  axilla,  and 
back  again  obliquely  over  the  same  shoulder,  crossing  the  first 
oblique  turn.  A  circular  turn  is  then  made  around  the  neck. 
The  circular  neck  turns  are  alternated  with  the  turns  passing 


i\J 

1 

1 

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■ 

ll^l 

1 

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H 

1^1 

^ 

^ 

y.: 

JH 

^^^^■K        ■^^ 

- 

^ 

■ 

^^^^ 

~lj 

^H 

^^^^v 

'  k. 

^^^1 

^^Hy 

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Fig.  54. — Figure-of-8  bandage  of  the  neck  and  axilla.     (Fowler's  Surgery.) 

under  the  axilla  and  crossing  over  the  shoulder.  Each  succeeding 
turn  overlaps  the  preceding  one  by  two-thirds  of  its  width.  A 
circular  turn  around  the  neck  completes  the  bandage. 

Combined  Neck  Bandage. — K  combination  of  head,  neck,  and 
chest  turns  is  useful  in  securely  retaining  the  dressing  after  an 
extensive  dissection  in  the  cervical  region  (Fig.  55). 

Ascending  Spica  Bandage  of  the  Shoulder. — ^The  initial  extrem- 
ity of  the  roller  (Fig.  56)  is  fixed  by  means  of  one  or  two  circular 
turns  around  the  arm  of  the  affected  side  at  the  level  of  the 
axillary  fold,  or  a  short  distance  below  it.  The  roller  is  carried 
directly  across  the  anterior  aspect  of  the  chest  to  the  axilla  of 
the, opposite  side,  under  the  axilla  to  the  posterior  aspect  of  the 

6 


82 


OPERATING    ROOM    AND    THE    PATIENT 


chest,  and  finally  across  this  to  the  starting-point.  A  circular 
turn  is  next  made  around  the  arm  at  the  starting-point,  and  then 
a  second  turn,  similar  to  the  first,  but  ascending  and  covering 
in  two-thirds  of  the  previous  turn,  except  at  the  opposite  axilla 
where  the  turns  exactly  overlap,  is  made  around  the  chest. 
The  chest  turns  alternate  with  the  circular  tui'ns  around  the  arm, 
each  ascending  b}"  one-third  of  its  width  above  the  preceding  turn. 
In  this  manner  the  shoulder  is  ascended  by  spica  turns  until  it  is 


Fig.  55.— Combined  head,  neck,  and  figure-of-8  of  the  axilla. 
(Fowler's  Surgery.) 

completely  covered.  The  bandage  is  completed  by  a  circular 
turn  around  the  arm  and  there  fastened.  To  prevent  chafing 
of  the  opposite  axilla,  a  pad  of  cotton  should  be  held  in  place 
there  by  the  first  turn  of  the  bandage  around  the  chest. 

Descending  Spica  Bandage  of  the  Shoulder. — ^The  initial 
extremity  of  the  bandage  (Fig.  57)  is  secured  by  means  of  one  or 
two  circular  turns  around  the  arm  at  the  level  of  the  axillary 
fold  or  at  a  short  distance  below  it.  The  roller  is  carried  over  the 
shoulder  to  the  anterior  aspect  of  the  chest  as  high  up  as  it  can  be 
made  to  stay,  then  under  the  axilla  of  the  opposite  side,  around 
the  posterior  aspect  of  the  chest,  to  the  starting-point,  where  a 


BANDAGING 


83 


circular  turn  is  taken.  These  turns  alternate  one  with  another, 
each  chest  turn  descending  by  one-third  the  width  of  the  preced- 
ing turn  until  the  shoulder  is  completely  covered  in.  The  band- 
age is  finally  completed  by  a  circular  turn  around  the  arm.  The 
same  precautions  are  taken,  as  regards  the  opposite  axilla,  as  in 
the  case  of  the  ascending  spica  of  the  shoulder. 

Velpeau  Bandage. — ^Two  or  more  roller  bandages  are  required. 
The  arm  of  the  affected  side  is  drawn  across  the  chest,  the  palmar 


Fig.  56. — Ascending   spica   of   the       Fig.  57.— Descending  spica  of  the 
shoulder.      (Fowler's  Surgery.)  shoulder. 


surface  of  the  fingers  resting  upon  the  sound  shoulder  near  the 
base  of  the  neck.  The  initial  extremity  of  the  roller  is  placed 
over  the  scapular  region  of  the  unaffected  side,  and  the  roller  is 
carried  over  the  point  of  the  affected  shoulder;  thence  it  is  carried 
down  across  first  the  outer  and  then  the  posterior  surface  of 
the  arm  of  the  same  side,  and  under  the  elbow  to  the  anterior 
chest  wall,  from  which  point  it  should  pass  diagonally  across  the 


84  OPERATING    ROOM    AXD    THE    PATIEXT 

anterior  chest  wall  upward  to  the  axilla  of  the  unaffected  side, 
and  under  the  axilla  to  the  starting-point,  thus  completing  the 
first  turn  (Fig.  58).  This  turn  is  repeated  in  order  firmly  to 
fix  the  initial  extremity  of  the  roller.  From  the  scapular  region 
the  roller  is  carried  directly  around  the  bod}',  passing  over  the 
elbow  of  the  affected  side  near  its  point,  thence  to  the  axilla 


Fig.  58. — Velpeau's  Bandage.     First  turn.      (Fowler's  Surgerj'.)  ^ 

of  the  sound  side,  and  thence  to  the  starting-point,  over  the 
scapular  region  of  the  sound  side  (Fig.  59).  These  turns  alter- 
nate one  with  the  other,  each  succeeding  turn  overlapping  the 
preceding  one  by  two-thirds  its  width,  and  the  shoulder  turns 
gradually  approaching  the  base  of  the  neck;  the  turns  cross  the 
elbow  and  gradualh"  ascend  the  arm  until  the  last  turn  passes 
across  the  wrist  and  is  secured  in  the  axillary  line  of  the  sound 
side  (Fig.  60).  In  apph-ing  this  bandage,  as  in  other  cases  in 
which  skin  surfaces  are  pressed  together,  a  layer  of  cotton  should 


BANDAGING  85 

be  placed  between  such  surfaces  and  plenty  of  drying  powder 
be  used  to  prevent  maceration  and  excoriation. 

The  Desault  bandage  consists  of  three  roller  bandages.  A 
wedge-shaped  pad  is  placed  in  the  axilla  of  the  injured  side. 
This  is  held  in  place  by  the  first  roller  of  the  bandage.  The 
initial  extremity  of  the  bandage  is  held  in  place  by  pressure  of 
the  fingers  of  the  left  hand  over  the  lower  ribs  of  the  injured 


Fig.  59. — Velpeau's  bandage.     Second     Fig.  60. — Velpeau's  bandage  corn- 
turn.      (Fowler's  Surgery.)  pleted.      (Fowler's  Surgery.) 

side;  the  bandage  itself  is  then  carried  obliquely  across  the 
anterior  aspect  of  the  chest,  over  the  shoulder  of  the  sound  side, 
and  thence  through  the  axilla  to  the  apex  of  the  shoulder,  when 
it  crosses  the  first  turn.  Then  it  passes  diagonally  across  the 
back  to  the  injured  side,  fixing  the  initial  extremity  by  passing 
over  it  low  down  on  the  ribs.  The  chest  is  then  ascended  by 
spiral  turns  which  thus  securely  fasten  the  wedge-shaped  pad  in 


86 


OPERATING    ROOM    AND    THE    PATIEXT 


position.  These  spiral  turns  ascend  to  the  level  of  the  axilla. 
The  arm  is  now  brought  to  the  side,  the  pad  acting  as  a  fulcrum. 
The  second  roller  of  the  Desault  is  a'  series  of  ascending  spiral 
turns  including  the  arm  and  chest.  These  turns  begin  just  above 
the  elbow  of  the  injured  side,  and  end  just  below  the  level  of  the 
shoulder. 

The  initial  extremity  of  the  third  roller  is  fixed  in  the  axilla 
of  the  sound  side  by  the  fingers  of  the  left  hand,  and  the  roller  is 
carried  obliquely  across  the  chest  to  and  over  the  shoulder  of 
the  injured  side,  directly  downward  to  the  elbow  of  the  injured 
side,  over  this  and  diagonally  up  across  the  chest  to  the  starting- 
point;  thence  the  roller  is  carried  obliquely  over  the  posterior 
aspect  of  the  chest  to  and  over  the  shoulder  of  the  affected  side 
directly  down  to  and  over  the  elbow  of  the  affected  side.     Thence 

it  passes  diagonally  across  the 
posterior  aspect  of  the  chest  to 
the  starting-point.  These  turns 
are  repeated  until  the  roller  is 
finished.  The  hand  is  supported 
by  a  bandage  sling. 

The  Desault  bandage  is  used 
in  fractures  of  the  clavicle,  the 
pad  being  the  fulcrum  over 
which  the  second  roller  forces 
the  arm  to  the  side  in  such  a 
manner  as  to  correct  the  inward 
displacement.  The  third  roller, 
by  elevating  the  shoulder,  cor- 
rects the  downward  and  forward 
displacement. 

Figure -of -8  Bandage  of  the 
Elbow. — The  bandage  (Fig,  61)  should  be  applied  with  the  elbow 
flexed.  The  initial  extremity  of  the  bandage  is  fixed  hj  one 
or  more  circular  turns  made  a  few  inches  below  the  elbow- 
joint.  The  roller  is  then  carried  across  the  flexure  of  the  joint 
and  a  circular  turn  is  made  a  few  inches  above  the  joint.  The 
roller  is  then  carried  obliquely  to  the  starting-point  and  a 
circular  turn  is  made  there.      Circular   turns   below   the   joint 


Fig.  61. — ^Figure-of-8  bandage  of 
the  elbow.      (Fowler's  Surgery.) 


BANDAGING 


87 


alternate  with  those  above  the  joint,  the  bandage  each  time 
obliquely  crossing  the  flexure  of  the  elbow.  The  circular  turns 
gradually  approach  the  tip  of  the  olecranon  from  both  directions. 
The  bandage  is  finally  completed  by  a  circular  turn  around  the 
flexure,  thus  covering  in  the  olecranon.  A  neater  effect  may  be 
produced  by  first  passing  a  circular  turn  around  the  flexure  of 
the  joint  and  over  the  tip  of  the  olecranon 
then  a  circular  turn  below,  and  then  one 
above,  and  so  on  until  the  joint  is  com- 
pletely covered,  each  turn  covering  in  two- 
thirds  of  the  preceding  one. 

Reversed  Spiral  Bandage  of  the  Upper 
Extremity. — The  initial  extremity  of  the 
bandage  (Fig.  62)  is  fixed  by  means  of  one 
or  two  circular  turns  around  the  wi'ist. 
The  roller  is  then  carried  obliquely  across 
the  back  of  the  hand  to  the  level  of  the 
last  phalangeal  joint.  Here  a  circular  turn 
is  made.  By  means  of  spiral  or  reverse 
turns  the  roller  ascends  the  hand  to  the 
metacarpo-phalangeal  joint  of  the  thumb, 
passes  obliquely  to  the  wrist,  where  a  cir- 
cular turn  is  taken  around  the  wrist,  thence 
back  obliquely  to  take  a  circular  turn 
around  the  body  of  the  hand.  Three  or 
more  of  these  figure-of-8  turns  are  made, 
thus  carrying  the  bandage  as  far  as 
the  wrist.  The  forearm  is  ascended  by 
means  of  spiral  or  spiral  reverse  turns,  ac- 
cording to  the  conformation  of  the  forearm, 
until  the  elbow  is  reached.  If  it  is  desired 
to  keep  the  arm  flexed  the  elbow  is  cov- 
ered by  a  series  of  figure-of-8  turns  while 
the  part  is  in  a  state  of  flexion.  If,  however,  the  arm  is  to  be 
kept  extended,  spiral  and  spiral  reverse  turns  are  continued 
over  the  elbow  and  up  the  arm.  The  bandage  is  completed  by 
one  or  two  circular  turns  at  the  level  of  the  axillary  fold.  Care 
should  be  taken  in  applying  this  bandage  that  the  reverses  do 


Fig.  62. — Reversed 
spiral  bandage  of  the 
upper  extremity. 
(Fowler's  Surgery.) 


88  OPERATIXG  ROOM  AXD  THE  PATIEXT 

not  press  over  bony  prominences,  as  the  ridge  of  the  ulna,  also 
that  the  reverses  are  in  accurate  alignment. 

Figure-of-8  Bandage  of  the  Hand  and  Wrist  (Dorsal). — The 
initial  extremity  of  the  bandage  (Fig.  63)  is  fixed  by  one  or  two 
circular  turns  around  the  wrist.  Thence  the  roller  is  carried 
oblic^uely  across  the  dorsum  of  the  hand  to  the  base  of  the  index- 
finger,  where  a  circular  turn  and  a  half  is  made  around  the  hand 
at  the  metacarpo-phalangeal  articulation.  The  roller  then 
returns  obliquely  to  the  wrist.     After  a  circular  turn  at  the 


pl 

V 

PP^ 

H^H 

Mii 

^ 

"^g 

H 

E 

|ft..4»=»,^V> 

•,  t  ^^K^i 

^^^^nm 

Fig.  63. — Figure-of-8  bandage  of  the   hand  and   wrist  (dorsal).    (Fowler's 

Surgery.) 

wrist  has  been  completed  the  roller  is  again  carried  obliquely  to 
the  base  of  the  index-finger,  and  a  second  circular  turn  is  made 
around  the  hand.  These  turns  are  continued,  each  overlapping 
the  preceding  turn  by  two-thirds  of  its  width,  until  the  dorsum 
of  the  hand  is  completely  covered.  A  circular  turn  at  the 
wrist  completes  the  bandage, 

Figure-of-8  Bandage  of  the  Hand  and  Wrist  (Palmar). — This 
is  applied  in  the  same  manner  as  the  dorsal  figure-of-8  of  the 
hand  and  wrist,  except  that  the  oblique  turns  cross  the  palm 
instead  of  the  dorsum  of  the  hand. 

Demi-gauntlet  Dorsal  Bandage. — ^The  initial  extremity  of  the 
bandage  (Fig.  64)  is  fixed  at  the  wrist  by  one  or  two  circular 
turns.  The  roller  is  carried  oblicjuely  across  the  back  of  the 
hand  to  the  base  of  the  thumb,  which  is  surrounded  by  a  circular 
turn,  and  the  roller  is  returned  to  the  wrist.  Here  a  circular 
turn  is  made,  and  the  roller  is  carried  obliquelj'  across  the  back  of 
the  hand  to  the  base  of  the  index-finger,  there  making  a  circular 
turn  and  again  returning  to  the  wrist.  This  is  continued  until 
the  base  of  each  finger  has  in  due  order  been  surrounded  by  a 


BANDAGING  89 

circular  turn.     The  bandage  is  completed  by  a  few  figure-of-8 
turns  of  the  hand  and  wrist. 

Demi-gauntlet  Palmar  Bandage. — ^This  bandage  is  applied  in 
the  same  manner  as  the  dorsal  demi-gauntlet  bandage,  except 
that  the  oblique  turns  from  the  wrist  to  the  bases  of  the  fingers 
pass  over  the  palmar  instead  of  the  dorsal  surface. 


Fig.   64. — The  demi-gauntlet  (dorsal)  bandage.      (Fowler's  Surgery.) 

Gauntlet  Bandage. — ^The  initial  extremity  of  the  bandage 
(Fig.  65)  is  fixed  by  means  of  one  or  two  circular  turns  at  the 
wrist.  The  roller  is  then  carried  by  an  oblique  turn  to  the  tip  of 
the  thumb,  and  the  thumb  covered  by  spiral  or  spiral  reverse 
turns.  Upon  the  completion  of  these  turns  the  roller  is  carried 
back  to  the  wrist,  a  circular  turn  made  there,  thence  to  the  index- 
finger,  which  is  bandaged  in  the  same  manner  as  the  thumb. 
In  like  manner  the  i^emaining  fingers  are  covered.  The  bandage 
is  completed  by  a  few  circular  turns  at  the  wrist,  or  additional 


90  OPERATING    ROOM    AND    THE    PATIENT 

figure-of-8  turns  may  be  passed  around  the  hand  and  wrist  for 
further  security. 

Spica  Bandage  of  the  Thumb. — ^The  initial  extremity  of  the 
bandage  (Fig.  66)  is  fixed  by  one  or  two  circular  turns  around 
the  wrist.  The  roller  is  then  carried  over  the  dorsal  aspect  of  the 
tip  of  the  thumb  and  there  a  circular  turn  is  made.  The  roller 
returns  to  the  wrist  and  a  circular  turn  is  made  around  the  wrist. 


Fig.  65. — Gauntlet  bandage.      (Fowler's  Surgery.) 

Thence  the  roller  is  again  carried  obliquel}^  across  the  dorsal 
aspect  of  the  thumb.  A  second  circular  turn  is  made  around  the 
thumb,  this  last  overlapping  the  first  turn  by  two-thirds  of  its 
width.  This  procedure  is  continued  until  the  thumb  is  covered, 
a  turn  around  the  wrist  completing  the  bandage.  A  few  re- 
current turns  may  be  first  placed  over  the  tip  of  the  thumb  if  it 
is  desired  to  include  this  in  the  bandage. 

Spiral  Bandage  of  the  Finger. — ^The  initial  extremity  of  the 
bandage   (Fig.  67)   is  fixed  by  two  or  three  turns  around  the 


BANDAGING 


91 


middle  phalangeal  joint.     The  bandage  is  then  carried  in  a  spiral 
manner  to  the  base  of  the  finger,  each  turn  covering  in  one-half 


Fig.  66. — Spica  bandage  of  the  thumb       (Fowler's  Surgery.) 

of  the  preceding  turn.  A  circular  turn  is  made  at  the  base  of 
the  finger  and  the  bandage  is  carried  by  means  of  spiral  turns  to 
its   starting-pont   at   the   middle   phalangeal  joint.     From  the 


Fig.  67. — Spiral  bandage  of  the  finger.      (Fowler's  Surgery.) 

posterior  surface  of  this  joint  a  recurrent  turn  is  now  passed 
directly  over  the  tip  of  the  finger  to  the  anterior  surface  of  the 


92 


OPERATING    ROOM    AXD    THE    PATIEXT 


joint,  the  fingers  of  tlie  operator's  left  hand  holding  this  turn 
taut  wliile  a  second  recurrent  turn  is  passed  back  over  the  inner 
half  of  the  finger  tip  to  the  starting-point  of  the  first  recurrent 
turn.  This  is  also  held  in  place  and  a  third  and  final  recurrent 
turn  is  passed  over  the  outer  half  of  the  finger  tip.  A  circular 
turn  .  secures  the  ends  of  these  three  recurrent  turns.  The 
bandage  is  then  carried  to  the  distal  end  of  the  finger  by  means 


Fig.  68. — Spiral  bandage  of  finger.     Second  method.      (Fowler's 
Surgery.) 

of  spiral  turns.  At  the  extremity  a  circular  turn  is  taken  that 
secures  the  recurrent  turns  which  extend  on  either  side  of  the 
finger  tip.  Finally,  by  means  of  spiral  turns  the  base  of  the  finger 
is  reached  and  the  bandage  is  fastened  there  by  splitting  it  long- 
itudinally for  a  distance  of  six  or  eight  inches,  then  knotting  it 
just  beyond  the  split  to  prevent  further  splitting,  and  tying  the 
ends  directly  around  the  base  of  the  finger;  or  the  bandage  may 
be  split  for  a  distance  of  ten  or  twelve  inches,  the  long  ends  being 


BANDAGING  93 

knotted  and  carried  around  the  wrist  once  or  twice  and  then  tied 
securely.  The  last  method  effectually  prevents  the  loosening  or 
falling  off  of  the  bandage. 

A  second  method  of  applying  the  spiral  bandage  to  the  finger 
is  to  fix  the  initial  extremity  of  the  bandage  by  taking  two  or 
three  turns  around  the  base  of  the  finger  (Fig.  68).  From  the 
posterior  aspect  of  the  base  of  the  finger  the  bandage  is  passed  di- 
rectly over  the  finger  tip  to  the  anterior  aspect  of  the  base  of  the 
finger.  The  second  and  third  recurrent  turns  are  passed  in  like 
manner  over  the  inner  and  outer  half  of  the  finger  tip.  A  circu- 
lar turn  at  the  distal  extremity  holds  these  in  place,  following 
which  a  series  of  spiral  turns  descend  to  the  base  of  the  finger 
where  the  bandage  is  completed  by  a  circular  turn. 

A  simpler  method  may  be  used  where  it  is  not  desired  to  cover 
in  the  finger  tip.  The  initial  extremity  of  the  roller  is  secured 
by  two  or  three  circular  turns  around  the  base  of  the  finger,  the 
finger  is  then  ascended  to  its  tip  by  spiral  turns,  a  circular  turn  is 
made  at  the  tip,  and  by  means  of  spiral  turns  the  base  of  the 
fi-nger  is  again  reached,  where  a  circular  turn  completes  the 
bandage. 

Reversed  Spiral  Bandage  of  the  Finger. — ^This  bandage  is 
applied  in  the  same  manner  as  any  of  the  spiral  bandages  just 
described,  with  the  exception  that  reverse  spiral  turns  are  used 
in  place  of  spiral  turns. 

Anterior  Figure -of -8  Bandage  of  the  Chest. — The  initial  ex- 
tremity of  the  roller  (Fig.  69)  is  fixed  by  means  of  the  index- 
finger  of  the  left  hand  over  the  middle  third  of  the  sternum. 
The  roller  is  then  carried  over  one  shoulder  to  its  posterior 
aspect,  under  the  axilla  of  the  same  side  to  the  anterior  aspect  of 
the  shoulder,  diagonally  across  the  chest  to  the  posterior  aspect 
of  the  other  shoulder,  under  the  axilla  to  the  anterior  aspect  of 
the  chest,  and  diagonally  across  to  the  starting-point,  thus 
forming  a  cross  over  the  sternum.  These  turns  are  repeated  a 
number  of  times.  The  bandage  may  be  modified  by  first  making 
a  few  circular  turns  around  the  chest  at  the  level  of  the  axillary 
fold  or  by  alternating  these  circular  turns  with  the  figure-of-8 
turns  (Fig.  70) .  The  turns  may  be  placed  in  such  a  manner  that 
each  shall  exactly  cover  in  the  preceding  one,  or  each  turn  may 


94 


OPERATING    ROOM    AND    THE    PATIENT 


overlap  the  preceding  one  by  two-thirds  of  its  width.  The 
bandage  is  fastened  by  pinning  through  the  intersections  over 
the  sternum. 


Fig.  69. — Anterior  figure-of-8  bandage  of  the  chest. 

Posterior  Figure-of-8  Bandage  of  the  Chest. — The  initial 
extremity  of  the  roller  (Fig.  71)  is  fixed  between  the  scapulae 
at  the  level  of  the  axilla  and  the  roller  is  carried  over  one  shoulder 


Fig.   70. — Anterior  figure-of-8  liandage  of  the  chest  modified.      (Fowler's 

Surgery.; 

to  its  anterior  aspect,  under  the  axilla  on  that  side  to  the  posterior 
aspect  of  the  shoulder,  and  thence  back  to  the  starting-point. 


BANDAGING  95 

In  a  similar  manner  the  roller  is  carried  around  the  other  shoulder. 
These  turns  alternate  first  around  one  shoulder,  then  around  the 
other,  until  the  bandage  is  finished.  The  point  of  intersection 
between  the  scapulae  is  pinned. 

Spiral  Bandage  of  the  Chest. — The  initial  extremity  of  the  roller 
(Fig.  72)  is  fixed  by  means  of  one  or  two  circular  turns  around  the 
chest  at  the  level  of  the  xiphoid  cartilage.     The  roller  then  gradu- 


Fig.   71. — Posterior  figure-of-8  bandage  of  the  chest.      (Fowler's 
Surgery.) 

ally  ascends  the  chest  by  means  of  spiral  turns,  each  turn 
covering  in  two-thirds  of  the  preceding  turn  until  the  level  of 
the  axillary  fold  is  reached.  Here  one  or  two  circular  turns 
complete  the  bandage.  The  spiral  turns  may  be  supported  by 
shoulder  straps  pinned  in  front  and  behind  (Fig.  73). 

A  second  method  of  completing  the  bandage  (Fig.  74)  is  to  make 
one  circular  turn  at  the  level  of  the  axillary  fold,  pass  under 
the  axilla  to  the  posterior  aspect  of  the  chest,  thence  obliquely 
to  the  opposite  shoulder,  over  this  to  the  anterior  aspect  of  the 
chest,  and  diagonally  down  over  the  turns  of  the  bandage  to 


96 


OPERATING    ROOM    AXD    THE    PATIENT 


the  xiphoid  cartilage  where  the  bandage  ends  and  is  pinned. 
Pins  are  inserted  to  fasten  this  last  oblique  strip  to  each  spiral 
turn  of  the  bandage. 

Single  Breast  Bandage. — The  roller  (Fig.  75)  is  started  from 
the  scapula  of  the  affected  side,  is  carried  over  the  shoulder 
of  the  opposite  side  to  the  anterior  chest  wall,  and  thence  under 


Fig.  72. — Spiral  bandage  of  the  chest.     (FoAvler's  Surgery.) 

the  affected  breast  and  obliquely  along  the  lateral  and  posterior 
chest  wall  to  its  starting-point.  This  turn  is  repeated  in  order  to 
secure  the  initial  extremity.  Again,  starting  from  the  point  of 
the  initial  extremity  over  the  scapula  of  the  affected  side,  the 
roller  is  carried  completely  around  the  chest  just  under  the 
affected  breast.  These  turns  are  alternated,  each  turn  covering  in 
its  corresponding  preceding  turn  by  two-thirds  of  its  width,  and 
thus  gradually  ascending  and  covering  in  the  breast  completely. 


BANDAGING  97 

Care  should  be  taken  that  the  affected  breast  is  compressed 
equally  and  that  the  other  breast  is  not  unduly  pressed  upon. 

Double  Breast  Bandage. — The  first  turn  of  this  bandage 
(Fig.  76)  is  the  same  as  that  of  the  single  breast  bandage.  The 
second  turn  is  a  circular  one  around  the  chest  just  below  the 
breasts.  The  third  turn  begins  at  the  point  of  the  initial  extrem- 
ity, and  the  roller  is  carried  around  the  chest  wall  to  the  under 


Fig.  73. — Spiral  bandage  of  the  chest.     Method  of  securing. 
(Fowler's  Surgery.) 

surface  of  the  second  breast;  then  it  passes  obliquely  up  over 
the  anterior  chest  wall  and  over  the  shoulder  opposite  the  breast 
thus  supported,  thence  over  the  posterior  chest  wall  to  the 
starting-point.  Turn  number  two  is  now  repeated,  then  turn 
number  one,  then  turn  number  three.  These  turns  are  repeated 
in  this  order,  each  breast  turn  covering  in  by  two-thirds  of  its 
7 


98  OPERATIXG    ROOM    AND    THE    PATIEXT 

width  the  corresponding  preceding  turn,  and  in  this  manner  both 
breasts  are  securely  and  neatly  covered. 

Ascending  Single  Spica  Bandage  of  the  Groin. — The  initial 
extremity  of  the  roller  (Fig.  77)  is  fixed  by  means  of  one  or  two 
circular  turns  around  the  body  just  above  the  level  of  the  iliac 
crest.     If  the  rioiit  groin  is  the  one  to  be  bandaged  the  roller 


Fig.   74. — Spiral  bandage  of  the  chest.     Second  method  of   securing. 
(^Fowler's  Surgery.) 

should  run  anteriorly  from  left  to  right,  and  vice  versa.  The 
roller  is  carried  from  the  summit  of  the  iliac  crest  opposite  the 
groin  to  be  bandaged,  obliquely  across  the  anterior  surface  of  the 
abdomen  to  the  outer  side  of  the  thigh  of  the  affected  side  at  the 
junction  of  its  middle  and  upper  third.  A  circular  turn  and  a 
half  is  made  around  the  thigh  at  this  point,  the  roller  emerging 
on  the  inner  side  of  the  thigh  and  crossing  the  first  oblique  part  as 


BANDAGING 


99 


Fig.  75. — Single  breast  bandage 
(Fowler's  Surgery.) 


Fig.  76. — Double  breast  bandage. 
(Fowler's  Surgery.) 


Fig.  77. — Ascending  single  spica  bandage  of  the  groin.      (Fowler's  Surgery.) 


100 


OPERATING    ROOM    AND    THE    PATIENT 


low  down  as  possible  in  the  middle  line  of  the  thigh ;  thence  it  passes 
over  the  gioin  to  the  lateral  aspect  of  the  iliac  bone  on  the  same 
side,  and  over  this  in  a  slightly  oblique  direction  to  a  point  above 
the  iliac  crest.  A  circular  turn  is  now  made  around  the  body 
just  above  the  iliac  crest,  as  in  the  first  turn  which  secured  the 
initial  extremity.  The  spica  turns  and  the  circular  turns  around 
the  thigh  are  alternated  with  the  circular  turns  around  the  body, 
the  two  former  ascending  by  one-third  of  the  width  of  the 
bandage.     In  this  manner  the  upper  third  of  the  thigh  and  all 


Fig.  78. — Descending  single  spica  bandage  of  the  groin.      (Fowler's  Surgery.) 

of  the  groin  are  completely  covered  in.  Either  the  circular  turn 
around  the  body  or  that  around  the  thigh,  or  both,  may  be  omit- 
ted. The  spica  turns  should  cross  each  other  exactly  in  the 
middle  line  of  the  thigh-  and  groin.  If,  in  bandaging  the  right 
thigh,  the  bandage  is  started  around  the  body  from  right  to  left, 
instead  of  from  left  to  right,  the  roller  will  then  of  course  be  car- 
ried obliquely  across  the  groin  from  the  lateral  surface  of  the 
iliac  crest  of  the  affected  side  to  the  internd  aspect  of  the  thigh 
at  the  junction  of  its  middle  and  upper  third,  where  a  circular 
turn  and  a  half  is  made.  The  roller  emerging  on  the  outer  side 
of  the  thigh  is  carried  obliquely  across  the  anterior  surface  of  the 
thigh,  crossing  the  first  oblique  part  of  the  spica  turn  in  the  middle 


BANDAGING  101 

line  of  the  thigh  as  low  down  as  possible,  and  is  carried  obliquely 
across  the  anterior  surface  of  the  abdomen  to  above  the  iliac  crest 
of  the  opposite  side  and  thence  circularly  around  the  body  to  its 
starting-point.  If,  in  bandaging  the  left  groin,  the  roller  is 
started  from  the  left  to  the  right,  the  above  description  also 
holds  good  for  that  side. 

Descending  Single  Spica  Bandage  of  the  Groin. — ^The  descend- 
ing spica  of  the  gi'oin  (Fig.  78)  is  applied  in  the  same  manner  as 
the  ascending,  and  consequently  the  same  description  holds  good 
for  both,  with  the  exception  that,  whereas  in  the  case  of  the 
ascending  spica  the  first  turn  is  placed  at  the  junction  of  the 
middle  with  the  upper  third  of  the  thigh,  and  the  subsequent 
spica  turns  ascend  from  that  point  by  one-third  of  their  width, 
in  the  case  of  the  descending  spica  the  first  turn  is  placed  as 
high  up  as  possible  and  the  subsequent  turns  descend  by  one- 
third  of  their  width  until  the  junction  of  the  middle  with  the  upper 
third  of  the  thigh  is  reached. 

Ascending  Spica  Bandage  of  Both  Groins. — The  initial  ex- 
tremity of  the  bandage  (Fig.  79)  is  fixed  by  means- of  one  or  two 
circular  turns  around  the  body  just  above  the  level  of  the  iliac 
crests.  The  roller  runs  from  left  to  right,  or  from  right  to  left, 
according  to  the  thigh  which  is  to  receive  the  first  spica  turn. 
Starting  from  the  iliac  crest  of  one  side  the  roller  is  carried  ob- 
liquely across  the  anterior  surface  of  the  abdomen  and  groin  to  the 
external  surface  of  the  opposite  thigh  at  the  junction  of  its 
middle  and  upper  thirds.  Here  a  circular  turn  and  a  half  is 
made,  the  roller  emerging  from  the  inner  side  of  the  thigh  and 
passing  obliquely  across  the  first  part  of  the  spica  in  the  middle 
line  of  the  thigh  as  low  down  as  possible,  then  obliquely  ascending  to 
the  lateral  surface  of  the  iliac  bone  of  the  same  side,  thence 
obliquely  around  the  body  posteriorly  to  the  opposite  iliac  crest. 
A  circular  turn  is  made  around  the  body  and  the  bandage  is  car- 
ried only  to  the  iliac  crest  opposite  the  groin  yet  to  be  bandaged. 
The  roller  is  then  carried  obliquely  across  the  back  to  the  lateral 
aspect  of  the  iliac  bone  of  the  opposite  side,  and  thence  obliquely 
over  the  anterior  surface  of  the  groin  of  that  side  to  the  anterior 
surface  of  the  thigh  at  the  junction  of  its  middle  and  upper  third, 
where  a  circular  turn  and  a  half  is  made.     The  roller  then  emerges 


102 


OPERATING    ROOM    AND    THE    PATIEXT 


on  the  external  surface  of  the  thigh  and  ascends  obliciuely  over 
the  anterior  surface  of  the  groin,  crossing  the  first  oblic^ue  part 
of  the  spica  turn  in  the  middle  line  of  the  thigh.  Thence  the 
roller  is  carried  oblicpely  over  the  anterior  surface  of  the  abdo- 
men to  the  opposite  iliac  crest,  where  a  circular  turn  is  made 
around  the  body.  These  turns  are  repeated  in  the  following- 
order:  first,  a  circular  turn  around  the  body;  then  a  spica  turn 
around  one  groin,  the  bandage  emerging  from  the  inner  side  of 


Fig.   79. — Ascending  spica  bandage  of  both  groins.      (Fowler's  Surgery.) 


the  thigh  after  surrounding  it;  then  a  circular  turn  around  the 
body,  and  a  spica  turn  around  the  other  thigh,  the  bandage 
emerging  from  the  outer  side  of  the  thigh  after  surrounding  it  by 
a  circular  turn;  then,  finally,  a  circular  turn  around  the  bod}', 
until  both  groins  and  the  upper  third  of  both  thighs  are  com- 
pletely covered  in.  The  circular  turns  about  the  boch'  accurately 
overlie  each  other  and  the  circular  turns  about  the  thighs 
ascend  by  one-third  of  their  width.  Either  the  circular  turns 
around  the  body  or  the  circular  turns  around  the  thighs  or  both 
may  be  omitted. 


BANDAGING 


103 


Descending  Spica  Bandage  of  Both  Groins. — The  descending 

spica  of  both  groins  (Fig.  80)  is  applied  in  the  same  manner  as 
the  ascending  spica,  with  the  exception  that  the  oblique  turns  in 
the  descending  spica  begin  to  cross  high  up  and  descend  to  the 
junction  of  the  middle  with  the  upper  third  of  the  thigh. 


Fig.  80. — -Descending  spica  bandage  of  both  groins.      (Fowler's  Surgery.) 

Figure-of-8  Bandage  of  the  Knee. — The  initial  extremity  of 
the  bandage  (Fig.  81)  is  fixed  by  means  of  one  or  more  circular 
turns  around  the  thigh  a  short  distance  above  the  knee-joint. 
The  roller  is  carried  obliquely  across  the  popliteal  space  to  the 
inner  surface  of  the  leg  and  surrounds  the  leg  by  a  circular  turn 
about  three  inches  below  the  joint.  The  roller  is  then  passed 
obliquely  upward  across  the  popliteal  space,  crossing  the  first 
oblique  turn  in  the  middle  line  to  the  inner  surface  of  the  thigh 
where  a  circular  turn  is  made  which  overlaps  the  preceding  circu- 


104 


OPERATIXG    ROOM    AND    THE    PATIENT 


lar  turn  at  this  point  by  two-thirds  of  the  •^■iclth  of  the  bandage 
and  approaches  the  knee-joint  by  one-third  of  its  ^\-idth.  The 
popliteal  space  is  again  crossed  to  the  circular  turn  below,  and 
here  is  made  another  circular  turn  which  ascends  toward  the 
knee-joint  by  one-third  of  the  width  of  the  bandage.  These 
turns  are  continued  first  above  and  then  below  the  knee,  the 
Tipper  ones  gradually  descending  and  the  lower  ones  gradually 
ascending  until  the  knee  is  entirely  and  securely  covered. 


Fig.  81. — ^Figure-of-S  bandage  of  the  knee.     (Fowler's  Surgery.) 

Figure-of-8  Bandage  of  Both  KJaees. — The  patient's  knees  are 
placed  closely  together,  being  separated  only  by  a  layer  of  non- 
absorbent  cotton  or  some  soft  material  to  protect  the  opposing 
bony  prominences  from  pressure.  The  initial  extremity  of  the 
bandage  is  fixed  by  means  of  one  or  two  circular  turns  which 
include  both  thighs  at  a  short  distance  from  the  knee-joints. 
The  roller  is  carried  obliquely  across  both  popliteal  spaces  to  a 
point  about  three  inches  below  the  knees,  where  a  circular  turn 
is  made  around  both  legs.  The  popliteal  space  is  again  obliquely 
crossed  by  the  roller  and  a  circular  turn  is  made  around  both  the 
thighs,  this  turn  overlapping  the  previous  turn  by  two-thirds  and 
descending  toward  the  knees  by  one-third  of  the  width  of  the 
bandage.  Again,  the  popliteal  spaces  are  crossed  to  the  turn 
below  the  knees  and  a  second  circular  turn  is  made  there,  this 


BANDAGING 


105 


turn  overlapping  the  previous  one  by  two-thirds  and  ascending 
toward  the  knees  by  one-third  of  its  width.  These  circular  turns 
are  repeated,  first  one  above  and  then  one  below  the  knees  until 
the  parts  are  completely  covered.  Finally,  to  complete  the  band- 
age, the  roller  is  passed  from  the  posterior  surface  between  the 
thighs  to  the  anterior  surface  of  the  bandage,  over  this  to  be- 
tween the  legs,  and  so  posteriorly  to  emerge  between  the  thighs, 
and  is  fastened  on  the  anterior  surface. 

Reversed  Spiral  Bandage  of  the  Lower  Extremity. — One  of  the 
foot  bandages  is  first  applied.  Instead  of  ending  the  foot  band- 
age at  the  ankle,  the  roller  (Fig.  82)  is  carried  up  the  leg  by 


-Reversed  spiral  bandage  of  the  lower  extremity. 
Surgery.) 


(Fowler's 


means  of  spiral  or  spiral  reversed  turns,  according  to  the  con- 
formation of  the  part,  until  the  knee  is  reached;  here  the  bandage 
may  be  ended  with  a  few  circular  turns,  or,  with  the  leg  in  the 
extended  position,  it  may  be  continued  on  up  the  thigh  to  the 
groin,  and  either  end  there  or  a  spica  of  the  groin  be  added  for 
additional  security.  If  it  is  desired  to  allow  the  patient's  knee 
to  remain  in  a  flexed  position,  the  figure-of-8  bandage  of  the  knee 
takes  the  place  of  the  spiral  or  spiral  reversed  turns  in  that  region. 
Short  Figure-of-8  Bandage  of  the  Leg. — If  the  leg  is  fairly 
well  nourished  this  is  the  best  bandage  to  use  (Fig.  38)  First 
apply  one  of  the  foot  bandages,  then  ascend  the  leg  by  means  of 
spiral  turns  until  these  can  no  longer  be  made  to  lie  Smoothly; 
here  the  figure-of-8  turns  begin.  The  bandage  is  carried  ob- 
liquely upward  and  around  to  the  median  line  posteriorly,  whence 
it  is  carried  obliquely  downward  and  around  to  the  front  of  the 
leg,  crossing  the  starting-point  as  near  the  median  line  as  is  per- 


106 


OPERATING  ROOM  AND  THE  PATIENT 


missible  without  bringing  too  much  pressure  over  the  long  ridge 
of  the  tibia.  These  figure-of-8  turns  are  repeated,  gradually 
ascending  the  leg  until  the  calf  is  covered.  The  bandage  is 
completed  by  one  or  more  circular  turns  around  the  leg  just  be- 
low the  knee. 

Long  Figure-of-8  Bandage  of  the  Leg. — The  initial  extremity 
of  the  bandage  (Fig.  39)  is  fixed  by  one  or  two  circular  turns 
around  the  ankle,  and  some  form  of  foot  bandage  is  then  applied. 
When  it  again  reaches  the  ankle  the  roller  is  carried  so  as  to  con- 
*  form  evenly  to  the  parts  by  an  oblique  turn,  but,  when  the  knee  is 
reached,  a  circular  turn  is  made  and  an  oblique  turn  is  carried  in 
a  downward  direction  until  the  first  circular  turn  at  the  ankle  is 
reached.  An  ascending  spiral  turn  is 
made  to  the  knee  and  an  oblique  turn  in 
the  downward  direction  is  repeated 
These  turns  are  repeated,  each  evenly 
applied  according  to  the  conformation  of 
the  limb,  until  the  entire  leg  is  securely 
bandaged.  This  bandage  is  one  of  the 
easiest  of  the  leg  bandages  to  apply  and 
affords  even  pressure. 

Figure-of-8  Bandage  of  the  Foot  and 
Ankle. — The  initial  extremity  of  the 
bandage  (Fig.  83)  is  fixed  by  a  circular 
turn  or  two  just  above  the  malleoli. 
The  roller  is  carried  obliquely  across  the 
instep  to  the  base  of  the  toes,  where  a 
circular  turn  is  made  and  the  roller  is 
returned  to  a  point  above  the  outer 
malleolus.  A  circular  turn  overlying 
the  first  circular  turn  is  then  made. 
These  turns  are  continued,  one  above  and 
one  below  the  ankle,  those  above  gradually  descending  and 
those  below  gradually  ascending  until  the  instep  and  ankle  are 
covered.  The  bandage  is  completed  by  a  circular  turn  around 
the  ankle. 

Spiral  Bandage  of  the  Foot. — ^The  initial  extremity  is  fixed 
by  the  finger  tips  placed  above  the  inner  malleolus.     The  roller 


Fig.  83.— Figure-of-8 
bandage  of  the  foot  and 
ankle.  (Fowler's  Sur- 
gery.) 


BANDAGING 


107 


is  carried  around  the  ankle  anteriorly;  it  crosses  the  initial 
extremity  and  thus  fixes  it.  The  roller  now  crosses  the  instep 
to  the  base  of  the  toes,  where  a  circular  turn  is  made.  Spiral 
turns,  ascending  the  foot  and  instep,  are  next  made  as  far  as  the 
conformation  of  the  parts  permits.  The  roller  is  then  carried  to 
the  ankle,  a  few  circular  turns  are  made,  and  the  terminal 
extremity  is  fastened. 

Spiral  Reversed  Bandage  of  the  Foot. — ^The  mode  of  application 
is  the  same  as  that  of  the  spiral  bandage,  except  that  spiral 
reversed  turns  are  employed  in  place  of  spiral  turns. 

Spica  Bandage  of  the  Foot  (Fig.  84). — ^The  initial  extremity 
is  fixed  by  a  circular  turn  or  two 
above  the  malleoli,  and  the  roller  is 
carried  obliquely  across  the  instep  to 
the  base  of  the  toes,  where  a  circular 
turn  is  made.  The  roller  is  carried 
obliquely  across  the  instep  to  the 
lateral  aspect  of  the  foot,  along  the 
lateral  aspect  to  the  posterior  sur- 
face of  the  heel  well  down,  thence 
along  the  lateral  aspect  of  the  foot 
obliquely  across  the  instep ;  it  crosses 
the  instep  and  turns  obliquely  in  the 
median  line  to  the  other  side  of  the 
foot.  This  completes  the  first  spica 
turn.  These  spica  turns  are  repeated, 
each  one  ascending  the  foot  by  one- 
third  of  the  width  of  the  bandage 
until  the  foot  and  ankle  are  covered 
in.  The  bandage  is  completed  by  a 
few  circular  turns  above  the  malleoli.  It  may  be  desirable  to 
apply  a  few  spiral  or  spiral  reversed  turns  around  the  instep 
before  beginning  the  spica  turns,  in  order  to  make  the  bandage 
look  neater.  The  intersection  of  the  spica  turns  should  always 
be  in  the  median  line. 

Serpentine  Bandage  of  the  Foot. — The  initial  extremity  of 
the  bandage  (Fig.  85)  is  fixed  by  means  of  a  circular  turn  or  two 
above  the  malleoli.     The  roller  is  carried  obliquely  across  the 


Fig.  84. — Spica  bandage  or" 
the  foot  and  ankle.  (Fowler's 
Surgery.) 


108  OPERATING    ROOM    AXD    THE    PATIENT 

instep  to  the  base  of  the  toes,  where  a  circular  turn  and  a  half 
is  made,  bringing  the  roller  to  the  middle  line  anteriorly.  The 
roller  is  carried  obliquely  to  the  outer  edge  of  the  sole,  then 
under  the  hollow  arch  of  the  foot  to  the  internal  lateral  aspect  of 
the  heel,  well  down,  thence  obliquely  up  over  the  posterior 
aspect  of  the  heel  to  the  external  malleolus,  and  obliquely  to  a 


Fig.  85. — Serpentine  bandage  of  the  Fig.  86. — Serpentine  bandage  of  the 
foot,  first  turn.  The  banda^  has  foot,  second  turn.  The  bandage  has 
been  made  to  include  the  great  toe.     been  made  to  include  the  great  toe. 

point  above  the  malleoli,  where  a  circular  turn  is  made.  This 
forms  turn  number  one.  The  roller  is  now  carried  obliquely 
across  the  instep  to  the  base  of  the  toes,  the  roller  naturally 
going  to  the  internal  aspect  of  the  base  of  the  toes,  whereas  in 
turn  number  one  it  came  to  the  external  aspect.  A  circular 
turn  and  a  half  is  made  around  the  base  of  the  toes.     Thence 


BANDAGING 


109 


the  roller  is  carried  obliquely  over  the  instep  to  the  internal 
edge  of  the  sole  of  the  foot,  then  onward  beneath  the  hollow  arch 
of  the  foot  obliquely  to  the  external  lateral  aspect  of  the  heel, 
well  down,  thence  obliquely  up  over  the  posterior  aspect  of 
the  heel  to  the  internal  malleolus,  and  obliquely  to  a  point 
above  the  malleoli,  where  a  circular  turn  is  made.  This  forms 
turn  number  two  (Fig.  86).     Turn  number  three  is  a  circular 


Fig.  87. — Serpentine  bandage  of  the  foot  completed.     (Fowler's  Surgery.) 

turn  around  the  instep  and  point  of  the  heel,  the  edges  of  which 
are  held  and  covered  in  by  a  repetition  of  turns  number  one 
and  two,  thus  completely  covering  in  the  heel.  Turns  number 
one,  two,  and  three  are  repeated  until  the  parts  are  sufficiently 
covered  (Fig.  87).  If  it  is  not  desired  to  cover  in  the  heel,  the 
circular  turn  number  three  may  be  omitted.  This  forms  the 
most  efficient  foot  bandage. 

Recurrent  Bandage  of  the  Foot. — ^Any  of  the  usual  foot  band- 
ages may  have  included  recurrent  turns  for  the  purpose  of 
covering  the  toes.  Combinations  of  spiral,  spiral  reversed, 
spica,  figure-of-8,  recurrent,  and  serpentine  bandages  of  the 
foot  may  be  used  as  indications  arise  in  individual  cases.  It 
may  sometimes  be  necessary  to  carry  spiral  or  spiral  reversed 
turns  above  the  ankle. 


110 


OPERATING    ROOM    AND    THE    PATIENT 


Spica  Bandage  of  the  Great  Toe  (Fig.  88). — This  is  applied  in  a 

manner  similar  to  that  employed  in  apph'ing  a  spica  of  the 
thumb.  The  initial  extremity  is  fastened  by  one  or  two  circular 
turns  above  the  malleoli.  The  bandage  then  crosses  the  instep 
obliquely  from  above  the  internal  malleolus  to  the  outer  side 
of  the  great  toe.  A  circular  turn  is  made  around  the  great  toe, 
as  near  the  tip  as  possible,  and  the  roller  is  carried  from  the 
inner  side  of  the  toe  obliquely  across  the  instep;  it  crosses  the 

first  oblique  part  of  the  spica  as  near 
the  tip  of  the  toe  as  possible  and  passes 
thence  above  to  the  external  mal- 
leolus. Here  a  circular  turn  is  made. 
If  desired,  the  tip  of  the  toe  may  be 
covered  in  by  a  few  recurrent  turns. 
The  spica  turns  are  repeated;  they 
ascend  toward  the  base  of  the  toe 
each  time  by  one-third  of  the  width 
of  the  bandage,  until  the  toe  is  com- 
pletely covered.  The  circular  turns 
may  be  omitted. 

Serpentine  Bandage  of  the  Great 
Toe. — The  initial  extremity  of  the 
bandage  is  fastened  by  means  of  one 
or  two  circular  turns  above  the  mal- 
leoli. The  roller  is  then  carried  obliquely  across  the  instep 
to  the  outer  edge  of  the  sole,  obliquely  under  the  sole  to  a 
point  just  posterior  to  the  thenar  eminence,  then  to  the  inner 
edge  of  the  foot,  and  finally  across  the  anterior  surface  of  the 
base  of  the  toe  to  its  tip.  Here  a  circular  turn  is  made  and  a 
few  recurrent  turns  may  be  added.  From  the  tip  of  the  toe 
the  roller  crosses  the  anterior  surface  of  the  base  of  the  toe, 
and  passes  thence,  obliciuely  across  the  base  of  the  other  toes, 
to  the  outer  surface  of  the  foot  to  a  point  opposite  the  hypo- 
thenar  eminence.  The  roller  passes  under  the  sole  obliquely, 
just  behind  the  thenar  eminence  under  the  arch,  to  emerge  at  the 
inner  edge  of  the  foot,  and  from  this  point  it  passes  obliquely 
across  the  instep  to  a  point  above  the  external  malleolus.  Here 
a  circular  turn  is  made.     These  serpentine  turns  are  repeated, 


Fig.  88. — Spica  bandage 
of  great  toe.  (Fowler's  Sur- 
gery.) 


BANDAGING 


111 


each  overlapping  the  preceding  one  to  a  slight  extent  until  the 
toe  is  completely  covered. 

'   COMPOUND    BANDAGES. 

Compound  bandages  are  used  for  the  most  part  to  take  the 
place  of  roller  bandages,  for  use  in  unskilled  hands.  They  are 
usually  made  of  unbleached  muslin  cut  to  conform  to  the  shape 
of  the  part  pf  the  body  to  which  they  are  applied.  They  are 
used  in  first-aid  dressing  on  the  battlefield;  but  few  of  the  band- 


. — Arm-sling. 


ages  are  useful  in  civil  practice,  as  they  afford  neither  the  comfort 
nor  the  security  of  the  well-applied  roller  bandage.  Of  those  used 
in  civil  practice  the  sling  is  the  one  most  frequently  employed. 
For  supporting  the  forearm,  a  yard  square  of  unbleached  muslin 
is  cut  diagonally,  two  triangular  slings  thus  being  provided;  or 
the  yard  square  may  be  folded  diagonally  on  itself,  thus  forming 


112  .  OPERATIXG    ROOM    AXD    THE    PATIEXT 

a  triangle.  The  apex  of  the  triangle  is  applied  beneath  the 
elbo"^',  the  portion  of  the  sling  next  the  body  is  carried  over  the 
opposite  shoulder,  the  other  portion  over  the  shoulder  of  the 
affected  side,  and  the  ends  are  fastened  by  knotting  them  at 
the  back  of  the  neck.  Enough  traction  is  used  to  insure  that  the 
body  of  the  triangle  affords  equal  support  to  the  entire  length 
of  the  forearm.  The  apex  of  the  triangle  is  secured  to  the  front 
of  the  sling.  To  afford  additional  security  the  two  sides  of  the 
sling  may  be  sewed  or  pinned  together  just  above  and  parallel 
with  the  forearm  (Fig.  89) , 

Another  variety  of  sling  for  the  upper  extremity  is  made  by 
using  a  strip  of  muslin  three  feet  in  length  and  of'  sufficient 
breadth  to  support  the  forearm.  A  bandage  or  binder  of  the  chest 
is  first  applied,  one  end  of  the  sling  being  pinned  in  front  to  the 
median  line  of  the  binder  or  bandage.  The  other  end  is  passed 
between  the  body  and  the  forearm,  beneath  the  latter,  and  around 
it  to  the  starting-point,  where  it  is  pinned  with  enough  traction 
to  afford  comfortable  support. 

Sling  for  the  Lower  Extremity. — A  long  external,  well-padded 
board  splint,  ten  inches  broad  and  extending  from  the  axilla 
to  a  point  below  the  heel,  is  secured  to  the  chest  and  pelvis  by 
a  bandage  of  adhesive  plaster.  A  strip  of  muslin  broad  enough 
to  surround  the  lower  extremity  is  used.  One  edge  of  the  long 
side  is  tacked  to  the  uppermost  edges  of  that  portion  of  the 
splint  which  corresponds  to  the  leg  and  thigh.  The  strip  is 
then  passed  under  the  leg  and  thigh  back  to  the  first  edge  and 
there  fastened,  sufficient  tension  being  used  to  support  the 
limb  comfortably. 

T-bandages  are  mostly  used  for  holdmg  perineal  or  vulvar 
dressings  in  place.  They  may  be  modified  to  secure  dressings 
in  other  parts  of  the  body,  such  as  the  head  and  face. 

The  single  T-bandage  (Fig.  90)  is  made  by  sewing  a  strip  of 
unbleached  muslin,  three  inches  wide  by  eighteen  inches  long, 
to  the  middle  of  another  strip  four  inches  wide  by.  forty  inches 
long.     The  edges  should  be  hemmed. 

The  double  T-bandage  (Fig.  91)  is  made  by  sewing  a  split 
strip  to  the  middle  of  the  long  strip.  The  long  strip  or  body  of 
the  bandage  may  be  made  wider  according  to  the  part  of  the 


BANDAGING 


113 


body  to  which  it  is  intended  to  apply  it.  Two  strips  may  be 
fastened  a  short  distance  to  each  side  of  the  middle  of  the  body 
of  the  bandage. 

Triangular  bandages  are  modified  T-bandages.  The  vertical 
strip  of  the  single  T-bandage  is  made  broad  at  the  base  and 
triangular  in  shape,  the  base  being  attached  to  the  body  of  the 
bandage.     This  form  of  bandage  is  useful  in  securing  dressings 


Fig.  90.— Single  T-bandage. 
(Fowler's  Surgery.) 


Fig.  91. — Double  T-bandage. 
(Fowler's  Surgery.) 


in  the  region  of  the  groin  (Fig.  92),  in  the  gluteal  region  and  in 
the  anal  region.  In  applying  a  T-bandage  to  retain  dressings 
against  the  perineum,  or  against  some  part  in  that  neighborhood, 
the  body  of  the  bandage  is  first  made  to  surround  the  pelvis 
and  then  is  fastened  in  the  median  line  in  front.  The  vertical 
strip  or  strips  are  then  drawn  taut  from  behind  forward  over  the 
dressing  and  are  secured  to  the  body  of  the  bandage  over  the 
lower  part  of  the  abdomen. 

When  the  T-bandage  of  the  chest  (Fig.  93)  is  applied,  the  body 
of  the  bandage,  ten  or  twelve  inches  broad,  is  made  to  surround 
the  chest,  being  fastened  by  pins  in  the  median  line  in  front  or  at 
one  side.     The  vertical  strips  are  then  brought  from  behind 


114 


OPEEATING  ROOM  AND  THE  PATIENT 


Fig.  92. — The  triangle  of  the  groin.      (Fowler's  Surgery.) 


Pig.  93. — T-bandage  of  the  chest.      (Fowler's  Surgery.) 


BANDAGING 


115 


forward  snugly  over  the  shoulder  and  fastened  to  the  body  of  the 
bandage  in  front. 

The  abdominal  T-bandage  or  abdominal  binder  (Fig.  94)  is 
made  of  two  thicknesses  of  unbleached  muslin,  or  of  one  thick- 
ness of  canton  flannel,  in  several  sizes,  from  ten  to  ei-ghteen  inches 
wide,  by  3/4,  7/8,  1,  11/8,  1  1/4,  and  1  1/2  yards  long.  The 
body  of  the  bandage  surrounds  the  abdomen  and  pelvis,  the  lower 
edge  of  the  body  of  the  bandage  reaching  well  down  on  the  thighs. 


Fig.  94. — The  abdominal  T-bandage.     (Fowler's  Surgery.) 

It  is  secured  in  front  with  safety  pins  and  the  vertical  strips  are 
passed  from  behind  forward  between  the  thighs  and  fastened 
anteriorly  to  the  body  of  the  bandage,  thus  securing  it  and  pre- 
venting it  from  slipping  up  upon  the  abdomen.  These  strips  are 
called  perineal  straps,  and,  instead  of  being  originally  part  of  the 
bandage,  they  may  be  pinned  in  place  after  the  body  of  the  band- 
age has  been  applied  so  as  to  permit  of  their  easy  removal  should 
they  become  soiled.  The  abdominal  binder  is  made  to  conform 
more  snugly  to  the  parts  by  pleating  with  safety  pins  on  each  side. 
Hernia  Bandage  (Fig.  95). — This  is  made  by  lengthening  the 
body  of  an  ordinary  triangular  bandage  sufficiently  to  allow 
the  body  of  the  bandage  to  encircle  the  body  twice.  A  three- 
inch  roller  is  attached  to  the  apex  of  the  triangle,  and  this  is  used 
as  a  spica  of  the  groin  after  the  triangle  is  applied. 


116 


OPERATIXG    ROOM     AXD    THE    PATIEXT 


The  breast  binder  (Fig.  96)  is  made  of  two  thicknesses  of  un- 
bleached   musHn    or    of    one    thickness    of    canton    flannel.     It 


Fig.  95. — Hernia  bandage.      (Fowler's  Surgery.) 


resembles  an  armless  jacket.     The  dimensions  are:  length,  one 
yard  and  one-fourth;  width,  at  the  back,  sixteen  inches,  in  front 


Fig.   96. — Breast  binder. 


eleven  inches,  under  the  arms  nine  inches.     The  body  of  the 
bandage  surrounds  the  chest  and  is  secured  by  i3inning  in  the 


BANDAGING  117 

median  line  in  front.  The  portions  corresponding  to  the  strips 
of  the  T-bandage  of  the  chest  are  fastened  over  each  shoulder 
with  safety-pins  (Fig.  97).  The  bandage  is  made  to  fit  snugly 
by  taking  pleats  in  the  sides  with  safety-pins.  This  bandage  is 
most  frequently  used,  after  a  radical  operation  for  carcinoma  of 
the  breast,  to  retain  dressings  and  to  afford  support  to  the 
opposite  breast. 


Fig.  97. — The  breast  binder  applied.      (Fowler's  burgery.) 


Four -tailed  Bandage.— This  is  a  modification  of  the  T-bandage. 
It  is  made  by  splitting  in  two  and  tearing  longitudinally  a  strip  of 
bandage  four  inches  broad  by  three  feet  long.  Each  end  is  split 
longitudinally  up  to  a  point  within  four  inches  of  the  middle  of  the 
strip.  The  unsplit  portion  is  the  body  of  the  bandage.  Such  a 
bandage  is  useful  in  retaining  certain  fractures  of  the  jaw  in 
position,  and  for  dressings  in  the  region  of  the  chin  (Fig.  98). 


118 


OPERATING    ROOM    AND    THE    PATIENT 


The  body  of  the  bandage  is  applied  to  the  symphysis  of  the 
lower  jaw.  The  upper  two  of  the  four  tails  are  carried  directly 
backward  to  beneath  the  inion  and  are  there  drawn  taut  and 
knotted.  The  lower  two  of  the  four  tails  are  carried  directly 
upward  until  the  vertex  of  the  skull  is  reached,  where  they  are 
drawn  taut  and  knotted.  The  four  ends  are  then  tied  tightly 
together  and  the  superfluous  part  of  the  bandage  is  cut  away. 


Fig.  98. — Four-tailed  bandage  of  the  jaw. 

Retractor  Bandages. — ^Modifications  of  the  T-bandages  are 
used  for  the  purpose  of  retracting  the  soft  parts  in  amputations, 
in  order  to  prevent  injury  to  the  soft  parts  while  section  of  the 
bone  is  made.  They  are  two-tailed  for  amputations  of  the 
humerus  or  femur,  and  three-tailed  for  amputations  of  the 
forearm  or  leg.  They  are  made  of  several  thicknesses  of  un- 
bleached muslin,  each  tail  measuring  twenty  inches  long  by 
eight  inches  wide  (Figs.  99  and  100). 

The  scultetus  (Fig.  101)  is  another  form  of  many-tailed  bandage. 
That  most  frequently  used  is  similar  to  an  abdominal  binder,  the 
binder  being  split  into  mam^  tails  from  each  extremity  to  a  point 
within  four  inches  of  either  side  of  the  middle  line  of  the  bandage. 
Such  a  bandage  is  useful  in  retaining  dressings  upon  an  abdominal 


BANDAGING 


119 


Fig. 


99. — Two-tailed  retractor. 
(Fowler's  Surgery.) 


Fig.  100. — Three-tailed  retractor 
used  in  amputation  of  the  leg. 
(Fowler's  Surgery.) 


Fig.  101. — The  scultetus  bandage.  The  appearance  of  the  bandage  before 
application  is  shown  in  the  upper  right-hand  corner  of  the  illustration. 
(Fowler's  Surgery.) 


120  OPERATING  ROOM  AXD  THE  PATIEXT 

"^'ound  and  in  exerting  even  pressure  during  paracentesis  ab- 
dominis. In  the  latter  case,  as  the  fluid  is  withdrawn  from  the 
abdomen  the  tails  of  the  bandage  are  drawn  tighter  and  tighter 
so  as  to  exert  even  pressure  upon  the  abdomen.  When  the 
scultetus  is  applied  for  retaining  abdominal  dressings  the  lower 
tails  of  the  bandage  are  first  brought  across  the  lower  part  of  the 
abdomen  and  fastened,  then  the  other  tails  are  alternately  brought 
into  place,  first  from  one  side  and  then  from  the  other  side,  from 
below  upward. 

Fixation  Bandages. — Bandages  in  which  are  incorporated 
materials  that  finally  harden  have  been  in  use  since  the  middle 
ages.  The  old  Arabic  physicians  Albugerig,  Athuriscus,  and 
Rhazes  used  bandages  in  which  were  incorporated  albumen, 
gypsum,  and  chalk.  The  use  of  such  bandages  was  apparently 
common  in  the  Orient  for  centuries,  Larrey,  in  the  course  of 
Napoleon's  Egyptian  campaign,  found  the  Egyptians  using  a 
hardening  mixture  of  white  of  egg,  camphor  spirits,  and  subace- 
tate  of  lead  in  cases  of  fractures  from  gunshot  injury.  He 
mentions  that  the  Greeks  for  a  long  time  had  used  a 
retentive  bandage  made  of  a  mixture  of  mussel  shells,  chalk, 
albumen,  oil,  and  hemp.  These  bandages  were  removed  by 
employing  the  solvent  action  of  a  steam  bath.  In  1798  the 
English  Consul  Eaton,  stationed  at  Bassora,  reported  that  the 
native  surgeons  had  been  successful  in  healing  a  complicated 
fracture  of  the  leg  in  a  soldier  by  means  of  plaster  of  Paris, 
This  was  a  case  in  which  the  English  naval  surgeons  were  about 
to  amputate  the  limb  Froiep  gave  further  publicity  to  these 
facts  in  1817,  and  two  Berlin  surgeons,  Kluge  and  Diefl^enbach, 
1828,  made  experiments  with  the  pi  aster- of -Par  is  bandage. 
Their  methods  were  so  crude  that  the  treatment  was  abandoned. 
The  extremity  was  oiled  and  placed  in  a  long  wooden  chest  which 
was  filled  with  a  pulp  of  plaster  of  Paris  After  the  hardening 
had  taken  place  the  lateral  boards  of  the  box  were  removed. 
A  Belgian  surgeon,  Seutin,  wrote  on  the  subject  in  1844.  Two 
Dutch  surgeons,  Mathysen  and  van  der  Loo,  in  1848  developed 
the  plaster-of-Pai'is  bandage  as  it  is  used  to-day. 

Pirogoff  and  Szymanowski  recommended  the  use  of  plaster-of- 
Paris    compresses   in   place    of   the   bandage — i.e.,   linen   strips 


BANDAGING  121 

dipped  in  a  paste  of  plaster  of  Paris.  This  form  has  the  advan- 
tage of  being  cheaper,  especially  if  the  skin  is  only  oiled  and  not 
bandaged  previous  to  the  application  of  the  plaster  compresses. 
It  has  the  disadvantage,  however,  of  making  a  dressing  that  is 
very  clumsy  and  that  can  be  removed  only  with  difficulty. 
Narrow  plaster-of-Paris  strips,  made  moist,  practically  do  all 
that  a  plaster-of-Paris  bandage  does.  These  folded  several 
times  may  .be  used  to  strengthen  weak  parts  of  the  applied 
plaster-of-Paris  bandage,  especially  at  the  joints.  Pasteboard 
splints  dipped  into  warm  water  may  be  adjusted  at  the  weak 
places,  or  a  rigid  splint  of  iron  or  iron  wire  (Esmarch)  may  be 
incorporated.  The  incorporation  of  such  additional  splints  is 
useful  where  it  is  desired  to  make  a  cast  as  light  as  possible. 
Beeley  recommends  that  plaster-of-Paris  splints  be  made  by  dip- 
ping strands  of  hemp  into  plaster-of-Paris  paste. 

The  Bavarian  splint  exemplifies  one  of  the  older  methods  of 
applying  plaster-of-Paris.  Two  pieces  of  flannel^  canton  flannel, 
or  other  similar  material  are  cut  to  conform  to  the  part  to  be 
enclosed  and  are  sewn  together  by  a  double  line  of  stitching 
lengthwise  in  the  middle  line.  The  inner  of  these  two  pieces  is 
applied  to  the  part  and  thickly  coated  with  plaster-of-Paris 
paste.  The  outer  piece  is  then  drawn  over  this,  and  the  whole 
moulded  to  the  part.  When  the  plaster  has  set,  the  dressing  is 
cut  down  in  the  middle  line  anteriorly.  This  allows  of  ready 
removal  and  inspection,  as  the  place  where  the  two  pieces  of 
material  were  sewn  together  acts  as  a  hinge.  A  much  neater 
method  of  application,  though  more  tedious,  consists  in  applying 
one  lateral  half  at  a  time,  waiting  for  it  to  harden,  and  then 
turning  the  edge  of  the  external  outer  half  of  the  material  over 
the  internal  half.  This  disposes  of  the  necessity  for  cutting  the 
cast.  The  whole  is  held  in  place,  after  hardening,  by  a  roller 
bandage. 

The  stocking  bivalve  plaster  splint  (Fig.  102)  is  made  of  two 
pieces  of  muslin  cut  in  the  shape  shown  in  the  figure  and  in 
size  to  fit  the  limb,  and  stitched  together  in  the  middle.  Be- 
tween the  two  layers  of  each  lateral  half  are  laid  twelve  or 
fifteen  layers  of  gauze,  cut  slightly  smaller  than  the  correspond- 
ing half  of  the  splint  and  soaked  in  plaster  cream.     The  whole  is 


122 


OPERATING  ROOM  AND  THE  PATIENT 


then  bound  in  place.  If  the  limb  swells  or  inspection  is  neces- 
sary, the  bandages  are  loosened  and  the  two  sides  of  the  splint 
turned  down,  the  line  of  stitching  behind  acting  as  a  hinge 
(Stimson) .    A  permanent  plaster-of -Paris  cast  is  applied  following 

the  subsidence  of  the  swelling  and  the 
assurance  that  the  reduction  is  as 
complete  as  possible. 

Manufacture  of  Plaster-of-Paris 
Bandages. — A  perforated  piece  of  tin 
one  inch  wide  and  a  length  equal  to 
the  width  of  the  bandage  is  shaped 
longitudinally  into  a  triangular  cage. 
This  serves  the  double  purpose  of 
acting  as  a  core  upon  which  to  wind 
the  bandage  and  of  allowing  of  a 
rapid  and  thorough  wetting  of  the 
bandage  when  immersed  in  the  solu- 
tion just  prior  to  use.       Plaster-of- 

Fig.  102.— Stocking  bivalve    Paris  bandages  are  rarely  rolled  by 
plaster      splint.         (Fowler  s 
Surgery.)  hand  at  the  present  time.     A  machme 

(Fig.  103)  is  used  which  allows  of  an 
even  distribution  of  the  plaster.  Wide-meshed  crinoline,  two, 
three,  or  four  inches  wide  and  of  the  usual  roller-bandage  lengths, 
forms  the  best  material  for  the  bandages,  as  the  wide  meshes  allow 
the  plaster  to  lie  in  them  and  not  on  the  surface  of  the  bandage 
w^here  it  is  liable  to  cake  during  application.  The  metal  core  is 
placed  on  the  spindle  of  the  bandage-rolling  machine,  and  the 
bandage  is  placed  on  this  and  wound  in  the  usual  manner,  except 
that  it  is  loosely  rolled  and  that  it  passes  through  the  box  con- 
taining the  plaster  of  Paris  and  becomes  impregnated  with  it 
as  it  is  being  rolled.  After  rolling,  the  bandage  is  pinned  to 
prevent  unrolling,  and  the  core  is  filled  with  plaster  of  Paris. 
Each  bandage  is  placed  in  a  separate  metal  receptacle  containing 
plaster  of  Paris,  or  several  bandages  may  be  placed  in  the  same 
receptacle.  Such  a  box  should  preferably  be  of  metal  and 
may  be  made  air-tight  by  sealing  with  adhesive-plaster  strips. 
Plaster  of  Paris  should  be  stored  in  a  dry  place.  As  an 
additional    safeguard   against   dampness  each  bandage  may  be 


BANDAGING 


123 


wrapped  in   oil  paper  and  an  elastic   snapped   about   this  to 
retain  it. 

Measures  of  Precaution  which  are  Necessary  while  the  Plaster- 
of-Paris  Bandage  is  being  Applied. — Before  the  application  the 
quality  of  the  plaster-of-Paris  should  be  inquired  into.  That  com- 
monly sold  often  contains,  besides  anhydric  calcium  sulphate,  so 


Fig.   103. — Plaster-of-I*aris  attachment  to  foot  machine. 

much  calcium  carbonate  that  it  does  not  harden  to  a  solid  mass 
after  being  mixed  with  water  in  which  calcium  carbonate  is  some- 
what soluble,  but  crumbles.  Plaster  of  Paris  which  has  been 
overheated  is  useless,  because  it  only  sparingly  takes  up  water. 
The  plaster-of-Paris  maybe  too  moist  and  consequently  is  likely  to 
have  lost  its  anhydric  qualities.  The  best  grade  of  dental  plaster 
should  be  used.  When  it  has  become  moist  it  may  be  dried  in  a 
pan  over  the  fire  before  using.  Less  pure  plaster  may  be  made 
to  harden  better  if  alum  is  added  to  the  water. 

The  precautions  which  have  been  noted  as  necessary  in  the 
application   of   bandages,   in   order   to   prevent   venous   stasis, 


124  OPERATIXG    ROOM    AND    THE    PATIEXT 

gangrene  and  ischemic  muscular  contracture,  must  be  even 
more  closely  observed  in  the  case  of  the  plaster-of-Paris  bandage, 
for  this  does  not  yield  at  all  to  swelliiig.  As  venous  stasis  in- 
creases rapidly,  care  must  be  taken  that  each  turn  of  the  bandage 
shall  cover  the  extremity  without  in  any  way  constricting  it. 
In  addition  the  patient  is  to  be  very  carefully  watched  during 
the  first  two  or  three  days,  and,  in  case  of  swelling  of  the 
peripheral  portion  of  the  limb,  the  bandage  is  to  be  split  longi- 
tudinally. If  this  does  not  suffice,  the  bandage  must  be  removed 
completely.  This  rule  must  be  particularly  observed  in  recenb 
fractures  treated  by  the  primary  use  of  the  plaster-of-Faris 
bandage.  Here  the  swelling  consequent  upon  the  injury  may 
induce  constriction  even  when  the  bandage  has  been  correctly 
applied.  The  specialist,  as  well  as  the  beginner,  must  give 
strict  attention  to  these  cases,  at  least  during  the  first  forty- 
eight  hours.  The  patient  should  be  further  instructed  to  report 
any  pain  or  swelling  at  once.  The  bony  prominences,  such  as 
the  malleoli,  the  crest  of  the  tibia,  the  tubercle  of  the  tibia,  the 
patella,  the  trochanter  major,  the  spine  of  the  ilium,  the  head  of 
the  ulna,  the  olecranon,  the  acromion  process,  and  the  heel,  must 
be  particularly  protected  against  jDressure  effects.  When  gauze 
or  cotton  is  applied  over  these  prominences  as  extensive  amount 
must  not  be  used,  other^\'ise  the  adjustment  of  the  plaster-of-Paris 
bandage  will  be  interfered  with  and  it  would  lose  somewhat  of 
its  fixing  effect.  In  case  pain  is  complained  of  at  one  of  these 
prominences  a  fenestra  should  be  cut  in  the  bandage,  but  openings 
should  not  be  cut  over  these  prominences  as  a  precaution,  for 
the  edges  of  such  openings  press  upon  the  soft  parts  and  allow 
of  swelling  where  the  supporting  effect  of  the  bandage  is  lost. 
In  case  the  bandage  covers  a  wound  from  which  discharge  is 
expected,  a  fenestra  should  be  cut  over  the  wound;  otherwise  the 
bandage  would  rapidly  become  moistened  and  ruined.  This  is 
done  after  the  hardening  process  is  complete.  The  edges  of  such 
fenestr?e  are  packed  carefully  with  gauze  and  coated  with  collo- 
dium  to  prevent  the  discharge  injuring  the  plaster  of  Paris.  In 
apphang  a  cast  in  such  a  case,  provision  may  be  made  for  dress- 
ing the  wound  by  not  covering  that  part  of  the  limb.  It  is, 
however,  easier  and  neater  to  cut  the  fenestra  later. 


BANDAGING 


125 


Application. — The  parts  are  placed  in  the  exact  position  in 
which  it  is  desired  that  they  remain,  and  this  position  is  retained 
during  the  appHcation  of  the  bandage  and  thereafter  maintained 
by  sandbags  laid  alongside  of  the  limb  until  the  plaster  has 
thoroughly  hardened.  The  hardening 
process  may  be  accelerated  by  allowing 
a  draft  of  air  from  an  electric  fan  to 
blow  upon  th§  bandage.  In  the  absence 
of  the  electric  fan  an  ordinary  fan  may 
be  used. 

Everything  which  is  to  be  employed 
in  the  application  of  the  cast  should  be 
at  hand  and  within  convenient  reach, 
so  that  the  cast  may  be  rapidly  ap- 
plied. The  bed  should  be  protected  by 
a  piece  of  rubber  sheeting,  and  the 
operator's  clothes  by  an  apron.  The 
skin  of  the  part  is  protected  by  coat- 
ing it  with  vaseline  and  covering  it 
with  a  layer  of  stockinet  material,  a 
cotton  stocking,  or  a  flannel  roller 
bandage  may  be  applied.  As  before 
noted,  particular  attention  is  paid  to 
the  protection  of  the  bony  promi- 
nences. Here  pads  of  cotton  are 
placed.  These  may  be  held  in  place 
by  strips  of  adhesive  plaster  or  by 
turns  of  the  flannel  bandage.  Band- 
ages made  of  thin  French  cotton  batting 
are  preferable  to  flannel  as  a  protecting 
bandage.  On  the  line  at  which  it  is 
desired  finally  to  cut  down  the  cast,  is 
placed  a  strip  of  adhesive  plaster  (Fig   104). 

A  sufficient  number  of  plaster-of-Paris  bandages  to  form  the 
cast  are  placed  near  a  basin  of  hot  water.  The  water  in  the 
basin  should  be  of  sufficient  depth  to  allow  of  complete  immersion 
of  the  bandages.  Two  bandages  are  laid  on  their  side  in  the 
water.     If  the  atmosphere  is  damp  or  if  the  quality  of  plaster  is 


I'ig.  104. — Flannel  roller 
and  adhesive  plaster  strip 
in  place  on  leg.  Ready  for 
the  application  of  plaster- 
of-Paris. 


126 


OPERATING  ROOM  AND  THE  PATIENT 


inferior,  a  small  quantity  of  salt  or  alum  may  be  added  to  the 
water  to  hasten  the  hardening  The  bandage  is  left  immersed 
until  it  is  thoroughly  saturated  and  is  then  lightly  squeezed  out, 
under  water,  to  force  out  air  from  the  interstices  and  allow  of 
further  saturation.  The  bandage  is  then  tightly  squeezed  to 
expel  the  excess  of  water.  As  soon  as  one  bandage  is  removed 
from  the  water,  another  is  substituted  for  it  until  the  required 
number  is  reached.  The  bandage  is  applied  evenly  and  smoothly, 
in  the  same  manner  as  an  ordinary  roller  bandage.  More 
numerous  turns  are  made  near  the  joints,  as  there  the  strain  is 
greatest.  The  number  of  bandages  used  will  depend  on  the 
purpose  for  which  the  cast  is  applied.  If  this  be  to  retain  a 
simple  dressing  in  place,  as  in  cases  of  scalp  wounds  with  delirium 
tremens,  one  or  two  bandages  will  suffice.  To  secure  immobiliza- 
tion of  joints,  from  six  to  eight  thicknesses  may  be  necessary 


Fig.  105. — Removal  of  plaster  cast. 

Fractures  of  the  leg,  when  the  patient  is  allowed  to  walk  about, 
require  heavier  casts  than  those  in  which  no  such  strain  is  put 
upon  the  damaged  bone.  In  the  former  instance  an  additional 
safeguard  may  be  furnished  by  the  introduction  of  a  thick  roll 
of  lamb's  wool  on  the  sole  of  the  foot  held  in  place  by  additional 
plaster  bandages.  When  fenestra  are  required,  the  plaster 
should  first  be  allowed  thoroughly  to  harden.  If  large  fenestrse 
are  needed,  the  cast  should  be  strengthened  by  incorporating 
in  it  one  or  more  strips  of  soft  iron,  bent  like  a  basket  handle, 
at  the  site  of  the  proposed  fenestrse.     The  cast  may  be  finished 


BANDAGING 


127 


in  one  of  two  ways,  either  one  of  which  enhances  its  appearance. 
The  final  bandage  may  have  its  selvage  left  on  and  is  then  to  be 
applied  as  a  short,  figure-of-8,  or  plaster-of -Paris  paste  may  be 


Fig.   106. — Knives  for  removal  of  plaster-of-Paris  casts. 

rubbed  in,  so  as  to  produce  a  smooth  finish.     Dry  plaster  may 
also  be  dusted  on  while  the  cast  is  still  moist. 

Removal. — After  the  cast  has  hardened  it  may  be  cut  down 
at  the  line  at  which  the  adhesive  plaster  was  placed  (Fig.  105) 


Fig.  107. — ^French  saw  for  the  removal  of  plaster-of-Paris  casts. 

This  is  desirable  when  the  plaster  is  applied  soon  after  the 
receipt  of  a  fracture,  as  it  allows  somewhat  for  swelling  and  also 
allows  of  the  cast  being  sprung  apart  by  the  hands  in  case 
swelling  becomes  more  pronounced.     The  cast  thus  cut  down 


128 


OPERATIXG    ROOM    AXD    THE    PATIENT 


is  held  in  place  by  a  gauze  bandage.     If  it  be  c-ut  down  when  its 
period  of  usefulness  is  past,  the  projecting  ends  of  the  adhesive 


Fig.  lOS. — Saws  for  the  removal  of  plaster-of-Paris  casts. 

plaster  strip  serve  as  a  guide  to  the  line  along  .which  to  cut,  and 
guard  the  skin  against  injury  from  the  instrument  employed. 
Many  instruments  have  been  devised  (Figs.  106,  107,  108,  109) 


Fig.   109. — Scissors  to  assist  in  the  removal  of  plaster-of-Paris  casts. 

for  removing  casts.  These  commonly  employed  are  the  strong 
resection  knife,  with  an  elevator  handle,  and  the  small  hand  saw. 
If  the  cast  is  cut  down  with  a  knife  it  will  be  found  easier  if  the 


BANDAGING  129 

cut  is  made  somewhat  obliquely  to  the  surface.  Painting  the 
proposed  line  of  incision  with  vinegar  facilitates  removal,  but 
this  should  not  be  done  if  it  is  intended  to  replace  the  cast,  as 
the  vinegar  softens  the  plaster  throughout  quite  a  distance. 
The  sensation  conveyed  by  the  knife  or  saw  will  tell  the  operator 
when  the  plaster  has  been  entirely  cut  through,  as  the  instrument 
will  catch  in  the  soft  protecting  material  beneath. 

When  the  cast  has  been  completely  cut  through,  the  edges 
are  pried  apart  sufficiently  to  allow  them  to  be  grasped  with 
the  fingers  and  then  separated  widely.  The  protecting  dressing 
is  then  cut  through,  and  the  entire  dressing,  cast  and  all,  is  held 
widely  separated  while  an  assistant  lifts  the  part  out  of  the  cast. 
This  mode  of  procedure  is  desirable  in  order  to  disturb  the  parts 
as  little  as  possible.  If  it  is  decided  to  replace  the  same  cast 
the  edges  may  be  bound  with  adhesive  plaster  and,  after  being 
reapplied,  it  may  be  held  in  place  with  a  muslin  bandage. 

Either  vinegar  or  sugar  water  will  be  found  useful  in  removing 
plaster  from  the  operator's  hands.  Vaselin  rubbed  into  the 
subungual  spaces  and  about  the  nails  helps  to  keep  the  plaster 
from  adhering. 

Plaster  Splints. — These  may  be  made  in  two  ways.  A  cast 
may  be  applied  as  described  and,  after  it  has  hardened,  it  may 
be  removed  in  two  sections.  These  are  well  padded  and  the 
edges  bound  with  adhesive  plaster;  the  entire  splint  is  then 
held  in  place  by  adhesive  plaster  and  a  muslin  bandage.  A 
second  method  is  to  fold  the  bandage  on  itself  on  a  smooth 
surface,  thus  forming  a  flexible  splint  of  the  desired  width, 
length  and  thickness.  One  or  more  of  the  splints  are  moulded 
to  the  parts  in  such  a  manner  as  to  permit  of  ready  removal. 
While  hardening  they  are  held  in  position. by  a  few  turns  of  a 
gauze  bandage.  After  they  have  become  hardened  they  are 
lined  with  cotton,  applied  to  the  part  and  held  in  position  by 
adhesive  plaster  and  muslin  bandages. 

Starch  Bandages. — Seutin,  a  Belgian  surgeon,  in  1884,  advised 
the  use  of  starch  bandages  as  a  removable  immobilizing  dressing. 
Originally,  gauze  bandages  were  soaked  in  fresh  starch,  and  the 
starch  was  spread  between  the  bandage  turns  as  they  were 
applied.     Now,   however,    crinoline   bandages   are   used,   these 


130  OPERATING    ROOM    AND    THE    PATIENT 

containing,  as  a  rule,  enough  starch  to  act  as  a  hardening  dressing. 
If  the  amount  of  starch  is  deficient,  powdered  starch  may  be 
incorporated  in  the  meshes  of  the  bandage.  Before  appHcation 
the  bandage  is  immersed  in  hot  water  and  appUed  wet. 

Application. — ^The  limb  is  first  bandaged  with  an  ordinary 
flannel  bandage,  or,  in  the  case  of  the  lower  extremity,  a  stocking 
may  be  put  on.  A  strip  of  adhesive  plaster  is  placed  longi- 
tudinally along  the  anterior  aspect  of  the  limb  in  the  median 
line,  and  a  second  strip  along  the  posterior  aspect  in  the  median 
line.  These  strips  extend  for  the  full  length  of  the  proposed 
bandage,  and  serve  to  protect  the  limb  when  the  starch  cast  is 
cut  in  two  portions.  Several  layers  of  the  starch  bandage  are 
applied  in  the  same  manner  as  is  done  in  the  case  of  a  plaster- 
of-Paris  bandage.  Such  a  dressing  has  the  advantage  of  light- 
ness, but  it  possesses  the  disadvantage  of  becoming  firm  only 
after  from  twenty-four  to  forty-eight  hours,  during  which  time 
it  must  be  protected.  For  the  purpose  of  maintaining  the  parts 
in  position  during  hardening  of  the  starch,  wooden  splints  may 
be  employed;  or  an  outer  layer  of  plaster  of  Paris,  which  is 
removed  after  forty-eight  hours  (Rosen),  may  be  used.  The 
starch  cast  has  the  additional  advantage  of  being  readily  cut 
with  stout  scissors. 

Soluble-glass  Bandage. — ^This  form  of  fixed  dressing  is  cheaper 
and  lighter  than  plaster  of  Paris,  but,  as  it  takes  twenty-four 
hours  to  become  firm,  neither  it  nor  the  starch  bandage  can 
replace  plaster-of-Paris  in  the  treatment  of  recent  fractures  or 
for  use  in  the  correction  of  deformities.  Both  these  forms  of 
bandage,  however,  can  be  very  profitably  employed  as  a  later 
supporting  dressing  in  fracture  cases  and  in  cases  of  resection 
of  a  joint.  As  in  the  case  of  the  starch  bandage,  the  soluble- 
glass  bandage  must  be  supported  for  from  twenty-four  to  forty- 
eight  hours  either  by  wooden  splints  or  by  a  few  turns  of  a 
plaster-of-Paris  bandage.  The  application  of  the  soluble-glass 
bandage  is  quite  simple.  The  liquid  is  poured  into  a  basin,  and 
a  number  of  gauze  bandages  are  placed  in  the  solution  until 
they  become  saturated.  It  is  necessary  to  protect  the  skin 
against  the  action  of  the  liquid  either  by  means  of  a  flannel 
bandage  or  by  the  use  of  a  stocking,  as  the  liquid  contains,  in 


BANDAGING  131 

addition  to  the  hardening  potassium  silicate,  a  greater  or  less 
amount  of  free  potassium — an  agent  which  affects  the  skin. 
During  the  application  of  the  bandage  additional  liquid  is  poured 
between  the  layers  so  as  to  fill  the  meshes  of  the  gauze.  Longi- 
tudinal strips  of  pasteboard  may  be  interposed  to  strengthen  the 
bandage.  After  it  has  hardened,  the  bandage  may  be  removed 
in  two  sections  with  strong  scissors.  There  will  thus  be  formed 
two  splints,  the  edges  of  which  may  be  bound  with  adhesive 
plaster  and  so  protected  against  splintering.  The  splints  are 
then  held  in  apposition  to  the  parts  by  means  of  an  ordinary 
roller  bandage.  Less  commonly,  magnesite  is  similarly  employed. 
Starch  bandages  and  soluble-glass  bandages  have  the  advan- 
tage over  plaster-of -Paris  in  that  they  are  not  affected  by  moisture, 
but  this  disadvantage  of  the  plaster-of-Paris  bandage  may  be 
overcome  by  rubbing  the  bandage  with  a  solution  of  dammar 
resin  (Mitscherlich),  or  soluble  glass  may  be  poured  over  the 
final  layer  of  the  plaster-of-Paris  bandage.  Mixtures  of  soluble 
glass  and  plaster  of  Paris  harden  very  readily  and  are  insoluble 
in  water. 

Caoutchouc  Bandages. — ^These  are  of  advantage  in  young 
children.  Strips  of  caoutchouc  are  immersed  in  hot  water  until 
soft,  and  then  are  rolled  up  with  a  linen  roller  bandage  and 
dipped  in  cold  water  to  cause  them  to  harden  as  quickly  as 
possible.  The  resulting  bandage  is  light  and  rather  firm,  and 
is  not  affected  by  water.  They  have  the  disadvantage  of 
being  expensive.  Just  previous  to  application  the  bandage 
is  immersed  in  hot  water. 

Pressure  Bandages. — Pressure  bandages  may  be  used  to 
produce  pressure,  as  in  the  treatment  of  varicose  veins  of  the 
lower  extremities;  to  produce  hyperemia,  as  in  the  treatment  of 
infections  and  tuberculous  processes  occurring  on  the  extremities; 
to  control  effusions  in  joints  and  in  the  soft  parts,  and  to  pro- 
mote absorption  of  such  effusions;  to  control  hemorrhage.  For 
such  purposes  an  ordinary  muslin  roller  is  impracticable  as  it 
does  not  possess  elasticity  enough  to  produce  the  required  even 
pressure,  and,  if  tightly  enough  applied  to  exert  pressure,  it 
may  produce  injury  to  the  soft  parts.  For  producing  such 
pressure  effects  a  bandage  possessing  a  certain  degree  of  elasticity 


132  OPERATING  ROOM  AND  THE  PATIENT 

is  necessary  When  l^ut  a  slight  degree  of  elasticity  is  required, 
bandages  of  stockinet,  flannel,  or  Japanese  cr6pe  may  be  em- 
ployed. Such  bandages  exert  uniform  pressure  and  do  not  irri- 
tate the  skin.  When  a  more  pronounced  pressure  effect  is  in- 
dicated, an  India-rubber  or  a  cotton-elastic  bandage  should  be 
used. 

The  dimensions  of  the  bandage  vary  -with,  the  purpose  for 
which  it  is  to  be  used.  A  Martin's  India-rubber  bandage  is 
the  one  commonly  employed  in  cases  of  varicose  veins.  When 
it  is  desired  to  render  the  extremity  bloodless  a  thick  rubber 
bandage — Esmarch  bandage — is  employed.  For  the  immediate 
control  of  hemorrhage  occurrmg  in  the  course  of  an  extremity, 
and  for  the  control  of  hemorrhage  occurring  after  the  extremity 
has  been  rendered  bloodless  by  the  Esmarch,  an  India-rubber 
tourniquet  is  employed.  This  is  a  long,  narrow,  thick  India- 
rubber  band  having  a  chain  attached  to  one  end  and  a  hook  to 
the  other,  by  means  of  which  it  is  secured  in  place  after  having 
been  wrapped  tightly  about  the  limb  at  the  point  where  the 
main  artery  is  superficial — in  the  case  of  the  upper  extremity, 
well  up  to  the  axillary  fold;  in  the  case  of  the  lower  extremity, 
well  up  to  the  groin.  Over  the  course  of  the  artery  is  first  placed 
an  ordinary  roller  bandage,  and  this  is  secured  in  position  by 
circular  turns  of  the  tourniquet,  which  is  finally  fastened  by  the 
hook  and  chain.  Care  should  be  taken  that  too  much  pressure 
be  not  employed,  otherwise  the  skin  and  underlying  soft  parts 
may  be  injured.  Some  protection  maybe  afforded  by  placing  a 
folded  towel  around  the  parts  before  applying  the  tourniquet. 
If  too  extreme  pressure  is  emploj^ed,  or  if  the  tourniquet  is  kept 
applied  for  too  long  a  period,  there  results  a  vaso-motor  paresis 
which  predisposes  to  secondary  hemorrhage.  The  common 
mistake  made  in  applying  a  tourniquet  is  to  apply  it,  in  opera- 
tions upon  the  forearm  and  hand,  just  above  the  elbow,  in  which 
event  pressure  upon  the  musculo-spiral  nerve  may  result  in 
paralysis;  or,  in  operations  upon  the  leg  and  foot,  in  applying  it 
just  below  the  knee,  at  which  point  pressure  upon  the  peroneal 
nerve  is  likely  to  result  in  paralysis  of  the  muscles  supplied  by 
that  nerve. 

Application  of  the  Esmarch  Bandage — The  bandage  is  started 


BANDAGING 


133 


at  the  distal  end  of  the  extremity  and  ascends  by  oblique  turns, 
the  edges  of  which  just  touch  each  other.  When  the  entire  ex- 
tremity has  been  ascended  by  these  oblique  turns  a  few  circular 
turns  may  be  made,  these  circular  turns  being  lifted  up  over  the 
course  of  the  main  artery  by  the  fingers  of  the  left  hand,  and 
the  remaining  part  of  the  body  of  the  bandage  being  placed 
vertically  under  them,  so  that  the  circular  turns  hold  the  body  of 
the  bandage  against  the  main  artery  and  effectually  shut  off 
the  blood  supply  (Fig.  35).  Beginning  at  the  distal  extremity 
the  oblique  turns  are  now  unwound  up  to  the  level  of  the  circular 
turns,  the  loose  part  of  the  bandage  being  bunched  and  held  out 
of  the  way  by  a  few  loosely  applied  turns  (Fig.  110).     In  opera- 


Fig.  110. — Esmarch's  bandage,  showing  hard  roller  in  position  over  the 
vessel  and  secured  by  the  last  fev/  turns  of  the  bandage.  The  roll  in  front 
is  the  loose  bandage  unwound  from  the  limb,  gathered  in  a  roll,  and  placed 
for  convenience  of  disposition  beneath  a  few  loosely  applied  turns. 
(Fowler's  Surgery.) 


tions  for  malignant  growths  or  for  septic  conditions  the  bandage 
should  not  be  applied  from  the  distal  extremity  of  the  limb  and 
continued  up  the  limb,  as  the  adoption  of  this  course  might 
force  tumor  products  or  septic  materials  into  the  circulation,  or 
at  least  into  parts  of  the  limb  not  originally  invaded  by  the 
disease.  In  such  cases  the  limb  should  be  elevated  for  five 
minutes  and  then  the  Esmarch  bandage  should  be  started 
above  the  level  of  the  disease.  Instead  of  finishing  the  Esmarch 
by  inserting  the  body  of  the  bandage  beneath  the  last  few  circu- 
lar turns  over  the  main  artery  of  the  limb,   an  India-rubber 


134 


OPERATING    ROOM    AND    THE    PATIENT 


tourniquet  may  be  employed  at  that  point  and  the  Esmarch  then 
entirely  removed. 

Application  of  Martin's  India-ruhher  Bandage. — This  bandage 
is  three  inches  wide  and  four  yards  long.  To  its  terminal 
extremity  is  fastened  a  double  tape  for  the  purpose  of  securing 
the  bandage  after  it  has  been  applied.  This  is  chiefly  used  in 
varicose  conditions  of  the  lower  extremity.  A  turn  is  first 
made  about  the  ankle.  The  bandage  is  carried  to  the  base 
of  the  toes,  and  a  circular  turn  is  made  there.  The  limb  is 
ascended  by  spiral  turns,  the  bandage  ending  just  below  the  knee, 
Reverse  turns  are  not  necessary,  as  the  elasticity  of  the  bandage 
allows  it  to  conform  to  the  shape  of  the  extremity.  In  the  case 
of  very  muscular  subjects,  however,  it  may  be  necessary  to  use 
long  figure-of-8  turns  in  order  to  make  the  bandage  lie  smoothly. 
Even  pressure  should  be  exerted  from  the  base  of  the  toes  to  the 
knee.  The  bandage  is  secured  by  tying  around  the  limb  the  two 
tapes  which  are  attached  to  its  distal  end.     Such  a  bandage  is 

removed  at  night,  rinsed  with  warm 
water,  dried  with  a  towel,  and  hung  up 
loosely  to  air.  The  skin  of  the  limb  is 
kept  in  good  condition  by  light  massag- 
ing night  and  morning  with  alcohol. 
If,   in  spite  of  this,   a  tendency  to  an 


Fig.   111. — Bier's  method  of  securing  temporary  passive  congestion  in  the 
treatment  of  tuberculosis  of  a  part.      (Fowler's  Surgery.) 

eczematous  condition  exists,  due  to  daily  contact  of  the  rubber 
with  the  skin,  a  thin  flannel  bandage  may  be  applied  next  to 
the  skin  or  the  rubber  bandage  may  be  applied  over  a  white 
stocking.  For  use  in  the  Bier  hyperemia  treatment  of  tuber- 
culous joints,  or  of  infections  that  have  developed  in  the 
course  of  an  extremity,  a  much  shorter  rubber  bandage  may 
be  employed,  only  half  a  dozen  circular  turns  being  used  to 
produce  the  required  hyperemia.      The  skin  may  be  protected 


ANESTHESIA  135 


from  irritation  by  the  application  of  a  few  turns  of  a  flannel 
bandage.  The  parts  distal  to  the  area  in  which  it  is  desired 
to  produce  hyperemia  may  be  supported  by  a  rubber  or  by  a 
flannel  bandage  (Fig.  111). 


CHAPTER  IV. 
ANESTHESIA. 


Furniture.  Preparation  of  patient.  Prevention  of  post-anesthetic 
vomiting.  Special  preparation.  Preliminary  medication.  The  anesthetist. 
Selection  of  the  anesthetic.  Ether  anesthesia,  drop  method.  Compli- 
cations. Ether  vapor  anesthesia.  Chloroform  anesthesia.  Nitrous  oxid. 
Nitrous  oxid  and  ether.  Junker's  apparatus.  Trendelenburg  cannula. 
Tracheal  insufflation  anesthesia.  Spinal  analgesia.  Local  anesthesia. 
Artificial  respiration,  Sylvester,  Laborde.  Intralaryngeal  insufflation, 
Meltzer.     The  relation  of  acapnia  to  surgical  shock. 

The  furniture  of  the  anesthetic  room  (Fig.  112)  consists  of 
the  anesthetic  table,  oxygen  apparatus  on  a  wheeled  stand, 
gas  apparatus,  and  a  stool  for  the  anesthetist.  On  the  anesthetic 
table  is  placed  the  anesthetic  tray. 

The  oxygen  apparatus  should  have  the  tube  boiled  after  each 
use,  and  fresh  sterile  water  placed  in  the  bottle. 

On  the  anesthetic  tray  are  placed  ether,  ether  drop-bottle, 
and  ether  mask;  chloroform,  chloi'oform  drop-bottle,  and  chloro- 
form mask;  tongue  forceps,  aseptic  tongue  sutures,  mouth-gag 
sponge  forceps,  stick  sponges,  vaselin  or  oxid  of  zinc  ointment 
hypodermic  syringe,  aseptic  hypodermic  needles,  atomizer 
muslin  bandages,  bandage  scissors,  safety-pins,  pus  basin 
towels;  two  small  sterilized  glasses,  one  bottle  of  sterile  water 
a  minim  dropper,  a  glass  graduate,  and  the  restoratives.  These 
consist  of  a  4-ounce  bottle  of  half-strength  whiskey;  tablets  of 
strychnin  sulphate,  gr.  1/30;  digilin  solution;  caffein  benzoate, 
gr.  j;  Magendie's  solution  of  morphin,  ampules  of  camphor, 
saturated  solution  in  olive  oil,  and  ergotol.  The  ergotol  solution 
is  made  by  adding  1  dram  of  the  solid  extract  of  ergot  to  1  ounce 
of  a  1 :  3000  solution  of  formalin.  The  hypodermic  dose  is  30 
minims. 

Chloroform  and  ether  should  be  poured  into  blue  glass  grad- 


136 


OPERATING    ROOM    AND    THE    PATIENT 


uated  bottles  and  a  reserve  supply  should  be  kept  in  their  original 
packages. 

The  simplest  form  of  ether  mask  obtainable,  suited  to  the  drop 
method  of  administration  is  the  mask  to  use  under  all  but 
special  circumstances  mentioned  hereafter:  Examples  of  such 
masks    are   sold    under    the    name    of    Mayo's,    Ochsner's    or 


Fig.   112. — The  anestlietic  room. 

Schimmelbush's.  These  are  washed,  dried  and  fresh  covers  of 
gauze  or  flannel  put  on  for  every  case. 

On  a  reserve  anesthetic  tray  is  kept  some  form  of  vapor 
generating  anesthetic  outfit  for  special  cases,  Junker's,  Gwath- 
mey's,  or  as  described  below. 

Preparation  of  the  Patient. — ^Rest  in  bed  and  tonic  medication 
may  be  necessary  to  restore  a  lessened  factor  of  the  resistance; 


ANESTHESIA  137 

mental  training  toward  the  acquirement  of  absolute  confidence 
in  the  procedure  and  operator  is  an  element  of  importance.  In 
general,  severe  purging  is  to  be  avoided,  mild  laxative  measures 
being  sufficient.  Total  abstinence  from  food  for  at  least  five 
hours  prior  to  operation  is  necessary;  water  may  be  allowed  in 
any  reasonable  quantity.  Remove  all  clothing  and  put  on  a  loose 
garment  of  some  kind,  seeing  that  the  body  surface  is  at  all 
times  warmly  covered  and  as  dry  as  possible.  After  operation 
substitute  dry  for  the  sweat  soaked  garments.  Artificial  heat 
on  the  operating  table  can  never  be  out  of  place  and  many  times 
it  is  necessary. 

Prevention  of  Post-anesthetic  Vomiting. — The  patient's  nose, 
mouth,  and  pharynx  should  be  thoroughly  cleansed  by  spraying 
with  an  astringent,  mildly  antiseptic  solution  an  hour  before 
anesthetization.  Should  a  catarrhal  condition  be  present,  it 
should  receive  special  attention.  In  such  cases  the  spray  should 
be  used  every  three  or  four  hours  for  as  long  a  time  as  the  prepa- 
ration of  the  case  will  admit.  Spraying  the  throat  and  nose 
with  a  2  per  cent,  solution  of  cocain  directly  before  anesthetiza- 
tion will  be  found  valuable  in  lessening  the  irritability  of  the 
mucous  membrane  to  the  anesthetic,  and  thus  lessening  the 
amount  of  secretion.  The  patient's  head  is  turned  to  one  side 
and  slightly  lowered  during  and  after  anesthesia  to  favor  the 
flow  of  secretion  from  the  lower  angle  of  the  mouth  and  nose. 
The  stomach  should  be  empty,  but  the  patient  should  not  have 
been  too  long  deprived  of  food.  In  catarrhal  conditions  of  the 
stomach,  lavage  should  be  employed.  A  sufficient  amount  of 
the  anesthetic  is  to  be  administered  to  overcome  any  efforts 
at  vomiting  during  the  course  of  the  anesthesia.  The  struggles 
of  an  under-anesthetized  patient  cause  subsequent  muscular 
discomfort  and  lassitude.  This  should  be  particularly  avoided 
in  patients  with  a  weak  heart.  The  secretions  of  the  mouth  and 
nose  should  be  removed  as  fast  as  they  collect.  Stick  sponges  are 
provided  for  this  purpose.  The  admixture  of  oxygen  with  the 
anesthetic  tends  to  lessen  the  frequency  and  violence  of  the 
vomiting.  Oxygen  may  be  administered  for  from  fifteen  to 
thirty  minutes  following  the  withdrawal  of  the  anesthetic,  with 
excellent  results. 


138  OPERATING    ROOM    AND    THE    PATIENT 

Special  Preparation. — ^In  subjects  for  thyroidectomy  special 
preparation  is  necessary  with  the  idea  in  view  of  eliminating  the 
deleterious  psychic  assault  of  fear,  etc.  The  patient  is  made 
familiar  with  the  procedure  of  narcosis  by  administering  on  each 
of  several  days  prior  to  the  operation  a  few  whiffs  of  alcohol 
on  the  mask  and  if  possible  not  told  the  time  of  the  actual 
operation. 

The  fact  is  well  known  that  an  anesthesia  in  an  apprehensive 
nervous  subject  is  from  the  very  initiation  uneven,  difficult,  and 
many  times  fraught  with  serious  physical  collapse.  Fear,  resist- 
ance and  general  nerve  dissociation  produces  distinct  cell  dis- 
integration, increases  adrenalin  and  the  output  of  glycogen, 
inhibits  the  activity  of  the  entire  digestive  mechanism  and  may 
even  cause  albumin  and  casts  to  be  seen  in  the  urine. 

In  that  class  of  cases  where  cerebral  excitation  might  be  expected 
in  the  early  stages  of  the  narcosis,  as  is  the  case  in  the  alco- 
holic, plethoric,  etc.,  prevention  may  be  facilitated  by  the  shut- 
ting off  from  the  general  circulation,  that  blood  which  can  be 
sequestered  in  the  limbs  by  the  application  of  a  tourniquet  to 
their  bases  just  before  beginning  the  anesthetic.  Such  pro- 
cedure has  for  its  object,  diminution  of  the  amount  of  anesthetic 
needed;  ease  of  control  of  hemorrhage  during  operation  because 
of  lessened  venous  tension;  shortened  operation  as  the  result  of 
dryer  field;  lessened  intracranial  pressure,  therefore  lessened 
danger  of  death  from  disturbance  of  the  respiratory  mechanism; 
more  space  between  the  brain  and  skull  for  brain  surgery;  an 
unetherized  portion  of  blood  ready  to  be  set  free  as  a  means  of 
resuscitation  in  collapse. 

The  special  preparation  of  a  subject  about  to  be  operated  for 
prostatic  disease  reduces  to  an  appreciable  minimum  the  dangers 
of  an  anesthesia  which  otherwise  has  a  mortality  of  the  highest. 
The  subject's  margin  of  safety  must  be  raised  by  the  mitiga- 
tion of  the  sepsis,  nephritis,  and  intestinal  stasis  with  portal 
plethora. 

Having  prepared  a  patient  for  the  narcosis,  the  next  step  is  to 
see  that  he  is  properly  placed  (Fig.  113)  on  the  table  for  the 
operation.  Place  an  ordinary  surcingle  snugly  around  the  table 
and  patient's  legs  just  above  the  knees,  have  the  shoulder  sup- 


ANESTHESIA 


139 


ports  well  padded  and  in  place  ready  for  the  Trendelenburg  or 
prostatectomy  position,  the  arms  at  the  side,  palms  down,  well 
under  the  buttocks  or  folded  across  the  chest  and  fastened  with 
a  broad  soft  roller  of  gauze  around  the  forearms  from  wrist  to 
elbow.  In  cases  for  gastric,  gall-bladder  or  kidney  work  the 
kidney  bridge  of  the  operating  table  should  be  properly  situated 
under  the  part  to  be  elevated  so  that  no  later  change  of  position 
will  be  necessary.  In  all  cases  where  nitrous  oxid  is  to  be  the 
anesthetic  the  patient  should  be  placed  in  position  before  the 
anesthetic  is  begun;  especially  is  this  true  of  the  lithotomy  posi- 


Fig.  113. — Patient  in  position  for  anesthesia. 

tion,  for  spasm  of  the  limbs  is  common  even  with  deep  narcosis. 
In  cases  for  thyroidectomy  the  trunk  is  best  elevated  to  an  angle 
of  thirty-five  degrees  with  the  legs  and  the  head  dropped  back 
as  far  as  possible  without  interfering  with  breathing.  In  brain 
surgery  the  Gushing  or  other  head  rest  is  placed  in  position 
before  the  final  preparation  for  operation. 

The  use  of  preliminary  medication  in  the  form  of  mo-rphin, 
scopolamin,  pantopon,  chlorotone,  etc.,  has  an  important  bear- 
ing on  the  initiation  of  the  anesthesia  as  well  as  the  general  sur- 
gical aspect  of  the  case  immediately  post-operative.  Except  in 
the  aged,  the  very  young,  and  these  patients  in  whom  septicemia, 
anemia  or  other  diseased  conditions  have  already  done  what 
morphin  and  scopolamin  do,  namely,  depressed  the  associational 
power  of  the  brain,  the  preliminary  use  of  sedative  medication 
is  distinctly  indicated. 

At  least  one  hour  prior  to  operation,  give  hj^podermically 
one-eighth  grain  of  morphin,  or  one-sixth  grain  of  pantopon,  or, 
by  mouth,  fifteen  grains  of  chlorotone  and  if  the  desired  sedative 


140  OPERATIXG  ROOM  AXD  THE  PATIENT 

effect  of  the  medication  is  not  noted  by  the  time  for  anesthesia, 
give  another  one-eighth  of  morphin  or  sixth  of  pantopon. 
Scopolamin  is  distinctly  less  safe  than  other  sedatives.  With 
preliminary  sedative  medication,  much  less  anesthetic  can  be 
tolerated  by  the  subject. 

The  anesthetist  should  don  his  gown  and  cap,  but  need  not 
pi^t  on  his  mask  until  he  enters  the  operating  room.  He  should 
be  familiar  with  the  patient's  history  and  with  the  condition  of 
the  heart,  lungs,  and  kidneys.  He  takes  charge  of  the  case  from 
the  time  it  is  brought  to  the  anesthetic  room  until  it  is  placed  in 
charge  of  the  nurse  who  watches  it  until  consciousness  is  regained. 
He  should  endeavor  to  inspire  the  patient  with  confidence.  He 
should  see  that  all  foreign  bodies  are  removed  from  the  mouth 
and  that  respiration  is  not  impeded  through  constriction  of  the 
neck  or  chest  by  clothing  or  dressings.  In  catarrhal  conditions 
of  the  nose  and  throat  a  preliminary  spray  of  2  per  cent,  cocain 
solution  is  useful.  The  nose,  lips  and  skin  in  the  neighborhood 
should  be  anointed  with  vaselin  to  avoid  irritation  from  the 
anesthetic.  The  eyes  are  protected  by  covering  them  with  a 
dumbell-shaped  piece  of  gutta  percha  tissue  over  which  is  placed 
a  layer  of  wet  cotton.  If,  in  spite  of  this  precaution  the  eyes  are 
irritated,  they  are  irrigated  with  boric  acid  solution  and  a  com- 
press wet  with  boric  acid  solution  applied.  The  patient's  head 
is  turned  somewhat  to  one  side  to  facilitate  the  escape  of  secre- 
tions from  the  angle  of  the  mouth  and  the  nose.  The  position 
should  not  be  forced,  and  should  not  interfere  with  respiration. 
A  flat  pillow  is  placed  under  the  patient's  head  to  protect  the 
head  from  the  table.  The  head  is  raised  or  lowered  to  secure 
the  best  posture  for  breathing.  Proper  elevation  of  the  )iead 
tends  to  prevent  falling  back  of  the  tongue  and  jaw. 

The  anesthetist  should  call  the  operator's  attention  to  any 
deviation  from  the  normal  course  of  anesthesia  and  see  that 
stimulation  is  promptly  administered.  He  is  not  to  leave  the 
patient  for  any  reason  unless  some  one  is  at  hand  to  relieve  him. 
He  will  be  notified  by  the  operator  when  to  discontinue  the 
anesthetic.  The  anesthetic  is  discontinued  during  dilatation 
of  the  sphincter  preliminary  to  operations  upon  the  rectum. 
Otherwise  the  deep  inspirations  which  this  procedure  occasions 


ANESTHESIA  141 

would  cause  the  patient  to  become  too  profoundly  anesthetized. 
This  is  particularly  dangerous  in  chloroform  anesthesia. 

The  selection  of  the  anesthetic  depends  upon  the  condition  of 
the  patient  and  the  character  of  the  operation.  The  anesthetic 
which  will  be  borne  with  least  danger  and  yet  will  permit  of  all 
necessary  manipulations  in  the  operation  is  the  one  to  be  selected. 
Ether  is  first  and  foremost  the  general  narcotic  agent  combining 
greatest  efficiency  with  greatest  safety  and  ease  of  application. 
It  is  the  agent  of  choice  for  the  majority  of  operations  and 
patients,  and  should  be  so  chosen  unless  some  special  feature 
of  the  case  indicates  the  use  of  nitrous  oxid,  oxygen  or 
chloroform. 

Chloroform  has  practically  one  indication  and  that  is  in  those 
stout,  athletic,  plethoric,  resistant  individuals  or  those  habitu- 
ated to  the  use  of  alcohol  or  tobacco:  in  these,  all  of  the  toxic 
effects  of  ether  are  produced  by  the  efforts  to  subdue  them  long 
before  any  muscular  relaxation  or  quiet  can  be  attained  so  that 
the  ether  in  such  excessive  dosage  becomes  distinctly  more 
harmful  than  the  chloroform.  There  may  exist  advantages  in 
chloroform  in  the  presence  of  the  anasarca  of  kidney  or  cardiac 
disease  on  account  of  the  liability  of  ether  producing  pulmonary 
edema  and  again  in  the  case  of  intestinal  obstruction  where 
vomiting  is  so  often  the  factor  determining  sudden  death  at  the 
outset  of  anesthesia. 

Local  anesthesia  is  indicated  in  operations  occupying  short 
periods  of  time  and  those  in  which  the  nerves  supplying  the 
parts  can  be  readily  anesthetized;  also  in  operations  of  longer 
duration  in  which  ether  or  chloroform  is  absolutely  contrain- 
dicated,  the  operation  being  upon  a  part  of  the  body  which  is 
not  controlled  by  spinal  analgesia.  Nitrous  oxid  may  be 
indicated  in  some  of  these  latter  cases.  If  ether  or  chloroform 
is  contraindicated  either  by  the  character  of  the  operation  or  by 
the  weak  condition  of  the  patient,  or  by  advanced  lesions  of 
the  heart,  lungs,  or  kidneys,  we  must  employ  local  anesthesia 
or  spinal  analgesia. 

Ether  Anesthesia  (Drop  Method) . — Precaution  is  used  in  case 
of  ether  as  to  the  thermo-cautery,  flame,  etc.  The  patient's 
confidence  is  secured.     The  mask  is  applied  to  the  face  covering 


142  OPERATING    ROOM    AND    THE    PATIENT 

the  mouth  and  nose  and  the  patient  instructed  to  breathe 
regularly.  The  neck  and  face  are  covered  by  several  wet 
towels  except  for  a  space  the  size  of  a  silver  dollar  through 
which  the  ether  is  slowly  dropped.  While  the  mask  is  being 
arranged,  the  arms  and  lower  limbs  are  secured  in  position  and 
the  final  preparation  of  the  field  of  operation  begun.  This 
distracts  the  patient's  attention  from  the  anesthetic.  Con- 
versation calculated  to  allay  apprehension  and  divert  the 
patient's  attention  is  very  useful.  The  nurse  should  keep  a 
finger  constantly  upon  the  pulse.  Ether  is  added  drop  by  drop, 
slowly  at  first  and  then  more  rapidly.  If  added  too  rapidly  at 
first  the  patient  will  gag  and  struggle.  The  size  of  the  drop  is 
regulated  by  cutting  a  broader  or  narrower  point  on  the  gauze 
emerging  alongside  the  cork  of  the  ether  bottle.  By  this 
graduated  drop  method  the  patient  passes  into  a  state  of  primary 
unconsciousness.  This  state  may  be  transitory  and  a  state  of 
unconscious  struggling  may  ensue  or  the  patient  may  pass 
directly  into  a  state  of  profound  anesthesia.  This  primary  state 
of  unconsciousness  varies.  In  alcoholics  and  drug  habitues, 
it  is  of  brief  duration,  while  in  patients  profoundly  septic,  or 
in  shock,  this  stage  passes  directly  into  profound  anesthesia. 
Following  the  state  of  primary  unconsciousness,  there  is  usually 
some  unconscious  struggling.  This  is  more  marked  in  men 
than  in  women  and  is  most  severe  in  alcoholics  and  drug  habitues. 
During  this  stage  the  ether  should  be  dropped  faster,  the  cone 
pressed  firmly  over  the  mouth  and  nose,  the  jaw  held  forward, 
and  the  patient's  struggles  restrained.  In  restraining  the 
struggling  no  greater  force  should  be  used  than  is  absolutely 
necessary.  Misguided  efforts  in  this  direction  only  tend  to 
increase  the  struggling.  The  unconscious  movements  of  the 
patient  should  be  guided,  rather  than  forcibly  restrained. 

The  stage  of  excitement  gradually  subsides.  The  convulsive 
movements  become  less  and  less  marked.  The  later  part  of  this 
stage  is  marked  by  muscular  rigidity.  Muscular  relaxation 
gradually  follows.  The  respirations,  which  during  the  stage  of 
excitement  have  been  irregular,  spasmodic,  and  interrupted  by 
attempts  at  speech,  become  deep,  regular,  and  finally  stertor- 
ous.    The  conjunctival  reflex  disappears.     The  pupil  is  midway 


ANESTHESIA  143 

between  contraction  and  dilatation  and  responds  to  light. 
Deep  anesthesia  is  now  established.  Should  the  anesthetic  be 
continued  the  pupil  will  dilate,  will  not  respond  to  light,  and  the 
respirations  will  become  shallow,  marking  the  danger  stage  of 
anesthesia.  Should  the  anesthetic  be  discontinued,  the  pupil 
will  also  dilate,  but  will  respond  to  light,  the  respiration  will 
become  normal,  and  the  patient  will  regain  the  stage  of  excite- 
ment. Both  these  conditions  should  be  avoided.  The  an- 
esthetic having  been  thoroughly  established,  the  condition  should 
be  maintained  by  dropping  ether  on  the  mask  from  time  to  time. 
It  must  be  remembered  that  anesthesia  is  used  to  cause  un- 
consciousness and  consequent  freedom  from  pain.  With  the 
patient  strapped  in  position  very  deep  narcosis  is  unnecessary. 

If  there  is  a  tendency  for  the  jaw  to  drop  back  thus  interfering 
with  respiration  this  may  be  overcome  to  a  great  extent  by 
raising  or  lowering  the  head  to  a  level  at  which  respiration  is 
least  impaired.  If  this  is  not  sufficient  the  jaw  must  be  held 
gently  forward.  The  forcible  pressing  forward  of  the  jaw  may 
result  in  unilateral  dislocation  or  subsequent  pain,  or  even 
temporary  paralysis  from  pressure  on  the  facial  nerve.  The 
anesthetist  watches  the  respiration  and  pulse,  and  in  bad  cases, 
the  pupil.  The  respiration  will  be  the  best  guide  to  the  depths  of 
the  narcosis.  The  anesthetic  is  continued  until  muscular  re- 
laxation is  complete;  oxygen  may  be  combined  with  the  ether. 
If  rigidity  persists,  a  few  drops  of  chloroform  may  be  added. 
Difficult  cases  are  watched  very  carefully.  In  many  cases  the 
administration  of  oxygen  with  the  ether  will  cause  the  case  to 
pursue  a  normal  course  of  anesthesia.  From  this,  it  would  seem 
that  the  cause  of  the  condition  lies  in  an  imperfect  oxidation  of 
the  ether  through  insufficient  air-supply.  There  are  other 
cases,  patients  suffering  from  profound  sepsis,  deep  shock,  or 
severe  hemorrhage,  whose  pupils  remain  dilated  throughout, 
whose  respirations  are  shallow,  and  whose  relaxation  is  complete, 
but  whose  pulse  gains  force  under  the  stimulating  effects  of 
the  ether.     Such  cases  require  very  little  anesthetic. 

Complications. — Cyanosis  may  occur  during  any  stage  of 
anesthesia  and  results  from  insufficient  air-supply.  Occurring 
in  the  early  stage  it  is  due  to  spasm  of  the  glottis  or  to  accumu- 


144  OPERATING    ROOM    AND    THE    PATIENT 

lation  of  mucus  in  the  pharynx.  The  former  results  from  too 
rapid  administration  of  ether.  The  mask  is  immediately  re- 
moved, a  mouth-gag  inserted,  and  the  tongue  pulled  gently 
forward.  This  is  done  with  tongue  forceps  which  should  be 
so  constructed  as  not  to  crush  or  bruise  the  tongue.  As  soon  as 
the  patient  has  taken  two  or  three  deep  inspirations  the  mask 
is  replaced.  In  case  of  accumulation  of  mucus  or  vomited 
matter  in  the  pharynx,  the  cone  is  removed,  a  mouth-gag 
inserted,  the  pharynx  sponged  out,  and  the  anesthetic  then 
continued.  Later  on,  after  anesthesia  has  been  established, 
cyanosis  may  be  caused  by  the  administration  of  too  much  ether, 
which  results  in  falling  back  of  the  tongue,  accumulation  of 
mucus  in  the  pharynx,  or  ijaralysis  of  the  central  nervous  resipira- 
tory  mechanism.  In  the  latter  event  attempts  at  respiration  will 
cease.  The  anesthetic  is  immediately  discontinued,  the  mouth- 
gag  inserted,  a  suture  passed  through  the  tongue  transversely  to 
the  septum  one  or  two  inches  from  the  tip,  and  gentle  rhythmic 
traction  made  upon  the  tongue,  and  the  pharynx  sponged  out. 
If  the  patient  does  not  begin  to  breathe  immediately,  gentle 
rhythmic  traction  on  the  tongue  is  continued,  the  head  of  the 
table  is  lowered,  oxygen  is  administered  through  a  tube  placed  as 
well  down  to  the  glottis  as  possible  and  by  tightly  closing  the 
mouth  and  nose  forcing  the  oxygen  into  the  lungs;  atropin  sul- 
phate, gr.  1/50,  administered  hypodermically;  the  sphincter 
ani  widely  dilated,  and  artificial  respiration  begun  and  con- 
tinued until  breathing  is  reestablished  or  until  thirty  minutes 
after  cardiac  pulsations  have  ceased.  The  anesthetist  should 
attend  to  the  mouth-gag,  tongue,  jaw,  and  pharynx;  a  nurse 
should  hold  the  oxygen  tube  in  place;  two  assistants,  one  at 
each  side,  should  keep  up  the  artificial  respirations,  a  third  assist- 
ant should  dilate  the  sphincter;  a  second  nurse  should  administer 
the  hypodermic  stimulation;  a  third  nurse  should  bring  the  f  aradic 
battery,  connect  the  electrodes,  moisten  them,  and  place  one  on 
the  lateral  region  of  the  neck,  and  the  other  on  the  epigastrium, 
the  second  electrode  should  be  moved  over  the  chest.  It  is 
only  by  quick,  combined,  and  protracted  efforts  that  these  cases 
of  respiratory  paralysis  can  be  saved.  The  premonitory  signs 
are   not   marked.     The   patient  is  not  often  seemingly  deeply 


ANESTHESIA  145 

anesthetized.     The  respirations  stop  suddenly,  the  patient  gives 
a  gasp  or  two  and  then  is  quiet,  the  heart  action  continues,  and. 
cyanosis  becomes  marked. 

There  may  be  a  moderate  degree  of  persistent  cyanosis  due  to 
imperfect  oxidation  of  the  ether.  This  is  remedied  by  combining 
oxygen  with  the  ether.     Such  cases  require  careful  watching. 

The  condition  of  the  blood  in  the  field  of  operation  is  a  guide 
to  the  administration  of  the  anesthetic.  Should  the  blood 
become  dark,  the  operator  will  call  the  anesthetist's  attention 
to  the  fact.  Should  the  patient  be  manifestly  under  the  influence 
of  the  anesthetic,  the  ether  should  be  withdrawn  and  oxygen 
administered  until  the  blood  regains  its  normal  color.  Should 
the  patient  be  manifestly  not  under  the  anesthetic,  more  air 
or  oxygen  should  be  given  with  the  anesthetic.  An  experienced 
operator  will  know  intuitively,  aside  from  the  information 
given  him  by  the  anesthetist,  when  the  patient  is  in  danger. 

Primary  circulatory  failure  rarely  occurs  with  ether.  When  it 
does  occur,  there  is  usually  a  premonitory  acceleration  and 
weakening  of  the  pulse.  This  condition  should  be  combated  by 
the  administration  of  as  small  an  amount  of  ether  as  possible, 
combined  with  oxygen;  strychnin  sulphate,  gr.  1/20,  repeated 
if  necessary;  half-strength  whiskey,  one  syringeful  after  another 
until  the  pulse  responds;  ergotol  nxxxx,  given  when  the  pulse  first 
begins  to  flag;  all  these  alone  or  combined  may  be  useful.  Rarely, 
acute  cardiac  dilatation  occurs.  Treatment  other  than  immediate 
exposure  and  manipulation  of  the  heart  is  of  no  avail. 

Ether-vapor  Anesthesia. — ^Ether  is  most  scientifically  admin- 
istered by  means  of  some  form  of  ether-vapor  generating  device; 
such  technic  eliminates  the  element  of  refrigeration  present  in 
all  open  methods,  allows  most  certainly  for  minimization  of 
dosage,  removes  the  anesthetist  well  out  of  the  operative  field, 
allows  at  any  moment  the  adoption  of  nasal  or  tracheal  admin- 
istration for  special  operations  about  the  head  and  neck,  easily 
and  efficiently  permits  the  exhibition  of  oxygen  during  the 
narcosis  and  for  emergency,  and,  by  percolation  of  the  ether 
through  water  removes  deleterious  constituents  of  the  ether  that 
causes  vomiting,  bronchial  irritation,  acetonemia,  etc. 

The  most  convenient  form  of  vapor  apparatus  is  that  that 

10 


146 


OPERATING  ROOM  AND  THE  PATIENT 


bears  the  name  of  Dr.  J.  T.  Gwathmey,  but  one  can  be  easily 
constructed  like  that  in  the  accompanying  illustration  (Fig.  114). 
The  ether  bottle  is  graduated,  the  water  bottle  contains  hot 
water  scented  with  oil  of  terpineol  or  essence  of  orange,  and 
the  mask  is  of  the  Yankhauer  pattern  with  a  perforated  vapor 


Fig.  114. — Vapor  apparatus  for  anesthesia.  A,  bottle  containing  hot 
water  and  essence  of  orange;  B,  ether  bottle;  C.  chloroform  bottle  for 
ether  or  chloroform  at  descretion  of  anesthetist;  D,  mask  for  ordinary 
anesthesia,  connected  to  bottles  by  delivery  tube  E;  F,  Lombard  nasal 
tubes  for  nasal  insufflation  anesthesia ;  G,  vapor  delivering  mouth  gag  for 
■work  about  the  mouth  and  throat;  H,  foot  pump. 

delivery  tube  fastened  in  its  dome.  The  vapor  is  generated  by 
means  of  a  foot  pump  which  forces  the  air  through  the  ether 
bottle,  over  to  and  through  the  water  bottle  to  the  mask.  The 
mask  is  covered  with  a  towel  to  conserve  the  ether  vapor  and 
fastened  to  the  patient's  face  by  a  strip  of  adhesive  plaster.  An 
oxygen  tank  can  be  attached  to  the  vapor  delivery  tube  at  any 
point  from  the  bottle  to  the  mask  by  means  of  a  glass  Y  tube 
and  oxygen  given  with  the  ether  vapor  or  alone  in  case  of  need. 
In  refractory  subjects  of  the  chloroform  type  a  few  drops  of 
chloroform  may  be  needed  on  the  mask  at  the  initiation  of  the 


ANESTHESIA  147 

narcosis  to  hasten  the  induction  but  if  so  used  must  be  carefully 
watched. 

Chlorofortn  Anesthesia. — Chloroform  vapor  is  more  irritating 
than  ether  vapor,  so  a  liberal  amount  of  vaselin  must  be  used  on 
the  lips,  nose,  and  neighboring  skin.  It  will  be  found  advan- 
tageous as  a  routine  measure  to  spray  the  nose  and  pharynx 
with  10  per  cent,  cocain  solution.  This  seems  to  counteract  in 
part  the  dangerous  effects  of  chloroform  narcosis.  The  Esmarch 
mask  is  held  a  few  inches  from  the  patient's  face  and  chloroform 
dropped  slowly  upon  it.  The  mask  is  gradually  brought  nearer 
the  face,  but  not  in  contact  with  it,  still  slowly  dropping  the 
chloroform.  An  abundance  of  air  should  be  allowed  at  all 
times.  If  the  process  is  slow  the  patient  often  goes  under  with- 
out a  struggle.  If  hurried  there  will  be  struggling,  but  the 
effect  of  chloroform  in  concentrated  form  is  so  powerful  that 
when  it  is  '^ pushed"  the  anesthetization  becomes  profound 
almost  immediately.  Such  a  procedure  is  dangerous.  The  skin 
becomes  somewhat  pale,  the  reflexes  abolished,  there  is  a  slight 
accumulation  of  mucus  in  the  pharynx,  the  pupil  is  midway 
between  dilatation  and  contraction,  the  respirations  moderate 
in  depth  and  frequency.  Altogether,  the  patient  presents  a 
much  more  pleasing  picture  than  when  ether  is  employed. 

The  stage  of  excitement  is  shorter  with  chloroform  than  with 
ether  and  is  rarely  marked.  The  pupillary  reflex,  general  re- 
laxation, respiration,  and  pulse  must  be  carefully  watched. 
Respiratory  failure  is  not  common  as  a  primary  complication. 
Alcoholics,  however,  may  take  chloroform  quite  as  badly  as  they 
do  ether  and  the  same  cyanotic  conditions  develop.  They  are  to 
be  treated  in  the  same  way.  No  matter  how  troublesome  the 
patient,  chloroform  anesthesia  must  not  be  ''pushed."  When 
cardiac  failure  complicates  chloroform  anesthesia,  respiratory 
failure  quickly  follows  or  is  synchronous  with  it.  The  skin  be- 
comes blanched,  the  heart  stops,  perhaps  gives  a  throb  or  two  and 
then  stops  again.  There  is  no  warning.  Respiration  may  con- 
tinue for  a  few  minutes  and  then  ceases.  In  the  rare  cases  in 
which  respiratory  failure  precedes  circulatory  failure  some  hope  is 
held  out  for  restoring  the  patients,  but  in  true  circulatory  failure 
the  hope  for  a  successful  issue  is  a  very  faint  one.     Nevertheless 


148  OPERATING    ROOM    AND    THE    PATIENT 

the  same  procedure  should  be  gone  through  with  as  has  been 
described  under  ether  anesthesia.  Should  the  patient  revive 
and  it  be  deemed  expedient  to  proceed  with  the  operation,  ether 
should  be  substituted  for  chloroform.  It  will  be  found  advan- 
tageous in  all  cases  to  combine  oxygen  with  chloroform..  To 
facilitate  this,  the  oxygen  tube  is  pinned  to  the  inside  of  the 
chloroform  mask  or  a  special  tubed  mask  may  be  used. 

The  accident  of  chloroform  poisoning  in  narcosis  is  due  to  two 
main  errors  of  administrative  technic;  first,  actual  overdosage,  the 
result  of  the  administration  of  stronger  than  a  2  per  cent,  vapor, 
and  relative  overdosage,  which  occurs  early  in  the  narcosis  when 
the  anesthetist  fails  to  note  the  period  of  apnea  that  immediately 
succeeds  the  patient's  voluntary  excessive  breathing  when  start- 
ing the  anesthetic.  During  this  period  of  apnea  the  anesthetist 
continues  to  pour  chloroform  on  the  mask  with  the  result  that 
a  large  quantity  of  strong  vapor  lies  in  wait,  so  to  speak,  for  the 
long,  deep  respirations  that  invariably  follow  the  period  of  apnea. 
Acute  toxemia  is  the  result  and  consequent  collapse  frequent, 
therefore  the  bad  reputation  of  chloroform  in  the  early  stages  of 
anesthesia  and  for  short  simple  operations. 

Nitrous  oxid  is  the  safest  of  general  anesthetics,  but  is  satis- 
factory for  prolonged  use  only  in  the  hands  of  an  expert  anesthe- 
tist, and,  considering  all  sides  of  the  question,  is  to  be  selected  as 
the  anesthetic  of  choice  for  short  operations,  painful  dressings 
and  as  an  initiative  to  ether  narcosis  or  in  such  special  cases  as 
severe  sepsis,  where  the  cytolitic  effect  of  other  anesthetics 
contraindicates  their  use;  in  severe  anemia,  acute  or  chronic; 
in  marked  shock,  as  from  acute  traumatism  [or  perforative  per- 
itonitis; in  diabetes  if  an  anesthetic  is  mandatory  and  in  such  con- 
ditions as  strangulated  hernia,  as  an  aid  to  local  anesthesia. 
Its  use  is  contraindicated  in  empyema,  angina  Ludovici,  sub- 
lingual or  post-phaiyngeal  abscess,  or  other  conditions  where 
asphyxia  is  present  or  may  be  induced  by  the  procedures  of  the 
operation. 

For  all  short  administrations  of  nitrous  oxid  the  ordinary 
dental  outfit  is  satisfactory,  but  for  the  initiation  of  ether  nar- 
cosis or  prolonged  administration,  special  apparatus  is  necessary 
and  must  provide  for  the  admixture  of  oxygen  with  the  nitrous. 


ANESTHESIA  149 

The  method  adopted  as  the  best  in  this  country  is  that  of  Bennett, 
Gwathmey  or  Gatch,  the  latter  being  specially  used  in  the  pro- 
longed exhibition  of  nitrous  and  oxygen,  and  the  former  for  gas 
initiation  of  ether  narcosis  or  gas  alone. 

While  putting  a  patient  under  nitrous  oxicl  there  is  usually  a 
marked  increase  in  the  rate  and  depth  of  breathing;  if  the  pro- 
portion of  nitrous  and  air  or  oxygen  is  left  unchanged  the  patient 
becomes  cyanotic,  the  respirations  labored,  the  pulse  slowed  and 
in  very  faulty  administration  there  are  clonic  muscular  contrac- 
tions. These  are  phenomena  of  anoxemia  of  the  brain.  This 
deficiency  of  oxygen  nature  tries  to  overcome  by  increasing  the 
activity  of  the  respiratory  mechanism,  but  instead  of  this  in- 
creased activity  furnishing  more  oxygen,  more  nitrous  oxid  is 
inhaled  which  of  course  increases  still  further  the  oxygen  defi- 
ciency and  increases  the  oxygen  hunger,  hence  a  vicious  cycle 
between  the  gas  bag  and  the  respiratory  mechanism  is  established. 
Now  in  the  course  of  a  nitrous  anesthesia  if,  at  the  moment  there 
is  an  increased  respiratory  action,  a  specific  warning,  the  nitrous 
oxid  is  at  once  turned  off  and  air  or  oxygen  given,  the  respira- 
tory activity  will  be  immediately  smoothed  out.  The  constant 
admixture  of  sufficient  oxygen  will  prevent  this  vicious  cycle  of 
anoxemia.  For  all  surgical  purposes  the  administration  of 
nitrous  oxid  and  oxygen  to  the  exclusion  of  air  as  adopted  in 
the  Gatch  technic  is  the  method  to  be  preferred.  Familiarity 
with  the  instrument  is  necessary  to  its  proper  use. 

Nitrous  oxid  and  ether  is  a  very  satisfactory  method  of 
anesthesia.  The  gas-bag  is  filled  and  the  ether  compartment 
is  saturated.  The  patient  first  breathes  air  for  two  or  three 
deep  breaths,  then  gas  is  turned  on  and  inhaled  and  expired 
through  the  valves.  When  about  one-half  of  the  gas  in  the  bag 
has  been  used  in  this  way  the  valves  are  turned  so  that  the 
patient  breathes  in  and  out  of  the  bag.  Nitrous  oxid  anesthesia 
should  now  be  complete.  The  ether  is  now  turned  on  so  that 
the  patient  breathes  gas  mixed  with  ether.  No  air  should  be 
given  until  ether  anesthesia  is  complete.  This  takes  about 
three  minutes.  Anesthesia  may  be  continued  by  the  addition 
of  small  quantities  of  ether  as  required  and  the  admission  of 
oxygen. 


150  OPERATING    ROOM    AND    THE    PATIENT 

Junker's  Apparatus  (Fig.  115). — ^The  two  catheters  are  in- 
serted, one  in  each  nostril,  until  the  level  of  the  pharynx  is 
reached.  A  safety  pin  is  then  passed  through  each  catheter  to 
mark  off  the  proper  distance  to  which  they  are  to  be  reinserted 
in  case  of  removal.  A  narrow  piece  of  adhesive  plaster  wound 
once  around  the  tubes  and  fastened  to  each  cheek  serves  to 
keep  the  tubes  in  place.  In  coupling  up  the  apparatus  it  is 
essential  that  the  leading-to  tube,  the  tube  by  which  air  is 
.forced  through  the  chloroform,  be  properly  attached;  otherwise 
chloroform  liquid  instead  of  chloroform  vapor  will  be  forced 


i 


Fig.  115. — Junker's  apparatus. 

through  the  catheter  and  suffocate  the  patient.  After  testing 
the  apparatus  to  insure  its  proper  assembling  it  is  well  to  pack 
the  chloroform  receptacle  with  lambs'  wool  to  still  further 
guard  against  spray  instead  of  vapor  being  forced  through  the 
catheter.  The  apparatus  is  useful  in  operations  in  which 
anesthesia  by  the  ordinary  methods  would  bring  the  anesthetist 
in  the  way  of  the  operator. 

The  Trendelenburg  cannula  (Fig.  116)  is  useful  in  operations 
about  the  larynx  and  pharynx.  The  tube  is  introduced  through 
a  tracheotomy  opening,  and  the  little  air-bag  around  the  tube 
gently  inflated.  This  prevents  blood  descending  alongside  the 
tube.  Chloroform  is  given  drop  by  drop  on  the  gauze  covered 
cannula  in  the  usual  way,  or  better  attached  to  some  form  of 
vaporizing  bottle. 

Tracheal  Insufflation  Anesthesia. — ^Tracheal  insufflation  anes- 
thesia is  a  special  anesthetic  technic  suggested  by  Meltzer  and 


ANESTHESIA 


151 


Auer  of  the  Rockefeller  Institute  for  use  in  intrathoracic  surgery 
and  in  such  cases  as  have  heretofore  demanded  some  such 
procedure  as  Crile's  tubation  of  the  pharynx,  Kuhn's  intubation, 
or  the  Trendelenburg  cannula. 

In  intrathoracic  surgery  beside  maintaining  the  narcosis, 
it  prevents  the  occurrence  of  acute  pneumothorax  when  the 
pleural  cavity  is  opened,  by  distending  the  lung  with  an  internal 
pressure  of  fifteen  to  twenty  millimeters  of  mercury,  it  carries  on 
respiration  by  means  of  a  current   of  air  constantly  passing 


Fig.   116. — Trendelenburg  cannula. 


through  the  tracheal  tube  and  prevents  aspiration  of  throat  and 
mouth  contents  by  the  force  of  the  return  air  current  alongside 
the  tracheal  tube. 

In  operations  about  the  head  for  disease  of  the  mouth,  nose, 
sinuses,  and  maxillary  bones  it  prevents  blood  and  debris 
entering  the  trachea  with  respiration,  takes  the  anesthetist  well 
out  of  the  operative  field  and  provides  complete  oxygenation  of 
the  blood  despite  the  presence  of  obstruction  of  the  airways. 

Physiological  laboratories  and  increasing  experience  in  man 
have  given  much  evidence  that  the  tracheal  tube  in  the  trachea 
and  larynx,  the  direct  application  of  ether  vapor  to  the  bronchi, 
and  the  intrapulmonary  pressure  are  not  contraindicating 
factors  in  the  procedure. 

Technic. — Tracheal  insufflation  anesthesia  is  carried  out  by 


152 


OPERATING    ROOM    AXD    THE    PATIEXT 


means  of  special  apparatus  constructed  for  the  purpose.  The 
apparatuses  in  common  use  are  those  bearing  the  name  of 
Elsberg  and  Janeway,  but  simpler  and  less  costly  constructions 
(Fig.  117)  can  be  used  with  satisfaction  if  they  adopt  the  essential 


Fig.  117. — ^Apparatus  for  tracheal  insufflation  anesthesia.  Arranged  to 
administer  ether  vapor  or  nitrous  oxide  and  oxygen.  A,  ether  bottle; 
B,  -R-ater  bottle;  C,  valve  for  s-\^-itching  in  ether  as  desired;  D,  mercury 
manometer  and  safety  valve;  E,  rubber  tubing  for  attachment  to  nitrous 
oxide  tank;  F,  tube  to  oxv'gen  tank;  G,  silk  woven  tracheal  catheter  size  F; 
H,  introducing  forceps  for  catheter;  I,  by  pass  for  interrupting  air  current 
to  lungs;  J,  foot  pump,  -which  may  be  replaced  by  electric  motor  pump; 
K,  stop  cock  to  shut  oS  pump  when  nitrous  oxide  and  oxj-gen  are  being 
used. 


principles,  namely,  a  source  of  air  pressure  such  as  is  furnished 
by  a  foot  pump  or  electric  motor,  a  water  bottle  for  filtering 
and  moistening  the  air,  an  ether  bottle  equipped  with  a  valve 
that  will  regulate  the  varpng  quantities  of  ether  required,  and  a 
safety  valve  and  manometer  to  measure  the  internal  pressure 


ANESTHESIA  153 

of  the  apparatus  as  well  as  prevent  sudden  rise  of  pressure  in  the 
lung  causing  harmful  distention. 

The  tube  that  is  introduced  into  the  trachea  is  a  twenty-two 
or  twenty-four  French  urethral  catheter  silk  woven  or  soft 
rubber.  This  catheter  should  have  a  mark  at  a  point  twenty-six 
centimeters  from  its  end  to  indicate  the  distance  from  the 
teeth  to  the  bifurcation  of  the  bronchi.  The  tube  is  introduced 
through  a  direct  vision  Chevalier  Jackson  laryngoscope  or  by 
means  of  a  special  introducer  designed  by  Cotton  and  Boothby. 

Anesthesia  is  maintained  by  the  constant  pumping  of  the 
ether  ladened  air  stream  through  the  tracheal  tube  to  the 
bronchi  and  no  factors  except  the  technic  of  exhibition  differ 
from  other  forms  of  ether  administration. 

Spinal  Analgesia. — By  this  method  immunity  from  pain  may 
be  relied  upon  in  all  operations  up  to  the  level  of  Poupart's 
ligament.  In  the  vast  majority  of  cases  there  will  also  be 
immunity  from  pain  in  operations  up  to  the  level  of  the  umbilicus 
anteriorly  aiid  somewhat  higher  posteriorly.  Beyond  this, 
analgesia  cannot  be  relied  upon.  In  rare  cases,  it  may  extend 
as  high  as  the  second  rib.  In  cases  in  which  this  higher  area  of 
analgesia  is  obtained  the  Trendelenburg  position  may  be,  in 
part,  responsible.  Nor  is  analgesia  at  all  satisfactory  in  intraab- 
dominal operations.  This  is  particularly  true  in  inflamed  con- 
ditions of  the  peritoneum. 

During  and  following  the  period  of  analgesia  numerous 
unpleasant  symptoms  may  occur.  That  these  are  not  due  to  the 
cocain  alone  seems  to  be  proven  by  the  fact  that  the  same  symp- 
toms are  equally  marked  whether  a  large  or  small  dose  of  cocain 
be  employed  as  well  as  in  cases  in  which  antipyrin,  tropococain, 
or  chloretone  was  used,  and  in  one  case,  vertigo,  pallor,  cold 
sweat,  sighing  respiration;  rapid,  weak  pulse;  dry  cough,  nausea, 
and  vomiting  occurred  before  any  cocain  had  been  introduced 
and  after  but  a  few  drops  of  cerebrospinal  fluid  had  been  with- 
drawn. In  addition  to  these  unpleasant  symptoms  there  may 
occur:  headache,  chills,  and  involuntary  defecation  and  urination. 
On  the  other  hand,  the  course  of  analgesia  may  be  quite  free 
from  all  unpleasant  symptoms,  or  at  most  a  rise  of  temperature 
and  headache  may  develop  a  few  hours  afterward. 


154  OPERATING    EOOM    AND    THE    PATIENT 

In  order  to  avoid  respiratory  or  circulatory  depression  it  is 
customary  to  give  strychnin  sulphate,  gr.  1/20,  hypodermically 
fifteen  minutes  before  the  spinal  injection. 

Vertigo  is  seldom  noticed.  Nausea  occurs  in  about  one-half 
of  the  cases  five  to  ten  minutes  following  the  injection.  Actual 
vomiting  takes  place  in  about  one-third  of  the  cases.  It  rarely 
lasts  longer  than  two  minutes.  Dry  retching  will  exceptionally 
occur,  but  is  not  persistent.  Some  cases  seem  to  be  relieved  of 
their  nausea  and  vomiting  is  prevented  by  swallowing  a  cup  of  hot 
coffee  when  the  first  symptoms  appear.  Headache  occurs  in 
two-thirds  of  the  cases;  it  is  usually  frontal  in  character  and 
may  be  mild  or  severe,  coming  on  three  or  four  hours  after  the 
injection.  The  severe  form  may  become  general  and  last  for 
from  twenty-four  to  forty-eight  hours.  Treatment  is  of  slight 
avail.  Nitroglycerin  seems  to  be  the  most  efficient  drug  in  this 
connection.  Rise  of  temperature  is  a  fairly  constant  symptom. 
It  occurs  from  three  to  eight  hours  following  the  injection 
Usually  the  temperature  does  not  rise  higher  than  101°  to  102° 
F.  and  rapidly  returns  to  normal.  Involuntary  micturition 
and  defecation  occur  in  few  cases.  Sometimes  the  patients 
are  aware  of  these  occurrences  and  sometimes  not.  Pro- 
nounced chills  are  seldom  observed.  Pallor,  cold  sweat,  and 
sighing  respiration  have  only  been  noted  in  cases  in  which  there 
was  also  present  nausea,  vomiting,  and  rapid,  weak  pulse.  All 
of  these  unpleasant  symptoms  are  lessened  by  the  preliminary 
hypodermic  use  of  strychnin  sulphate,  gr.  1/20. 

Rules  for  Making  the  Injection/— 1.  The  instrument  employed 
may  be  a  fine  aspirating  needle  and  an  ordinary  solid-piston 
hypodermic  syringe.  A  special  needle  inclosed  by  a  cannula  is 
a  convenience  under  some  circumstances,  and  a  glass  barrel 
and  asbestos-piston  syringe  add  a  nicety  to  the  procedure. 
These  should  be  sterilized  by  boiling. 

2.  Give  the  patient  a  hypodermic  injection  of  1/20  grain  of 
sulphate  of  strychnin,  a  quarter  of  an  hour  before  the  injection, 
and  have  a  cup  of  hot  coffee  ready  should  nausea  occur. 

3.  The  cocain  is  sterilized  by  crushing  the  required  amount, 
usually  1/2  grain,  in  a  sterilized  spoon  and  pouring  on  a  few  drops 

1  George  R.  Fowler,  Medical  Review  of  Reviews,  April,  1901. 


ANESTHESIA  155 

of  chloroform  to  form  a  paste  (Bainbridge).     When  the  chloro- 
form has  evaporated,  add  from  15  to  30  minims  of  boiled  water. 

4.  A  soap  and  water  and  alcohol  cleansing  of  the  skin  of  the 
back,  with  proper  isolation  by  means  of  clean  towels  and  surgi- 
cally clean  hands  answer  the  requirements  of  asepsis. 

5.  The  position  of  the  patient  may  be  either  the  sitting 
position  upon  the  edge  of  the  operating  table,  leaning  well  forward, 
or  the  left  lateral  decubitus,  with  both  thighs  flexed  upon  the 
abdomen,  and  a  cushion  placed  between  the  left  loin  and  the  table 
to  prevent  lateral  deviation  of  the  spine  in  the  lumbar  region. 

6.  The  highest  point  of  the  crest  of  the  ilium  is  to  be  identified, 
and  upon  a  line  straight  across  the  back  from  this  point  will  be 
found  the  fourth  lumbar  vertebra.  The  depression  immediately 
above  this  or  the  one  below,  if  this  is  more  easily  identified,  is 
utilized  for  the  injection. 

7.  Select  a  point  about  half  an  inch  to  the  right  of  the  middle 
of  the  space  chosen  and  here  introduce  the  needle.  A  pre- 
liminary injection  of  a  few  drops  of  cocain  solution,  .first  in  the 
skin  itself  and  then  into  the  depths,  renders  the  patient  less  liable 
to  start  when  the  needle  is  introduced,  and  a  slight  incision  with 
the  scalpel  is  an  additional  precaution  against  infection. 

8.  Enter  the  needle  at  the  point  where  the  hypodermic 
puncture  has  been  made  and  direct  its  course  in  such  a  manner 
that  its  point  reaches  the  spinal  column  in  the  median  line.  A 
very  little  practice  will  enable  the  operator  to  estimate  the  angle 
necessary  to  hold  the  needle  to  effect  this.  Pass  the  needle 
slowly,  and  if  the  angle  has  been  correctly  estimated  and  the 
middle  of  the  space  between  the  spinal  processes  properly 
identified,  the  resistance  to  its  passage  will  be  but  slight,  until 
it  reaches  the  interspinous  ligament,  when  a  decided  and  appre- 
ciable increase  in  resistance  will  be  felt.  Should  it  strike  bone, 
withdraw  partially  or  entirely  and  change  its  course.  It  will 
be  more  likely  to  strike  the  upper  than  the  lower  lamina.  Once 
it  has  entered  the  spinal  canal,  unless  its  lumen  has  become 
blocked,  the  cerebrospinal  fluid  appears,  flowing  from  the  needle 
in  clear  or  slightly  blood-tinged  drops.  An  amount  approxi- 
mately equal  to  the  volume  of  solution  to  be  injected  is  allowed 
to  escape. 


156  OPERATING    ROOM    AXD    THE    PATIENT 

9.  Screw  upon  the  needle  the  h^-podermic  syringe  previously 
charged  with  cocain  solution  and  inject  slowly.  Leave  the 
needle  in  situ  with  the  S3'ringe  attached  for  half  a  minute,  so  as 
to  prevent  leakage  from  the  puncture,  and  then  withdraw. 
Pencil  a  little  collodion  over  the  point  of  puncture  and  cover 
with  a  small  piece  of  adhesive  plaster. 

10.  Test  for  analgesia  once  a  minute,  commencing  in  the  soles 
of  the  feet,  with  a  needle.  Simple  touch  sensation  is  not  abol- 
ished; the  patient  must  complain  of  actual  pain,  otherwise 
analgesia  is  established.  In  the  average  case,  numbness  and 
formication  in  the  feet  occur  in  from  one  to  three  minutes,  and 
analgesia  in  the  lower  extremities  in  from  four  to  six  minutes. 
In  from  seven  to  fifteen  minutes  the  analgesia  has  reached  to 
varying  points  between  the  umbilicus  and  the  level  of  the  fourth 
rib  in  the  line  of  the  nipple.  The  level  is  higher  posteriorly 
than  anteriorly.  The  analgesia  lasts  from  thirty  minutes  to 
an  hour  and  a  half,  according  to  the  quantity  of  cocain  employed, 
and  recedes  from  above  downward. 

Local  Anesthesia. — Hydrochlorate  of  cocain  is  employed  in 
1/2,  2,  4  and  6  per  cent,  aqueous  solution.  The  two  latter 
percentages  and  higher  up  to  10  per  cent,  are  used  as  topical 
applications  to  mucous  membranes.  Schleich's  solution  may 
be  made  from  tablets  or  ma}'  be  prepared  according  to  the 
following  formulas: 

Xo.  1  (Strong). 

Cocain  hydrochlorate gr.  j 

Morphin gr.  1/8 

Sodium  chlorid gr.  j 

Sterile  water oj- 

Xo.  2  (Medium). 

Cocain  hydrochlorate gr.  1/2 

Morphin gr.  1/8 

Sodium  chlorid gr.  j 

Sterile  water o  j  • 

Xo.  3  (Weak). 

Cocain  hydrochlorate gr.  1/20 

Morphin gr.  1/16 

Sodium  chlorid gr.  j 

Sterile  water oj. 


ANESTHESIA  157 

Cocain  solutions  should  preferably  be  freshly  prepared.  This 
is  easily  done  by  Bainbridge's  method.  A  known  quantity  of 
the  crystals  or  a  tablet  is  ground  into  a  fine  powder  in  a  sterile 
spoon.  To  this  is  added  a  few  drops  of  chloroform,  and  a  paste 
made  by  thoroughly  mixing  the  two.  The  chloroform  soon 
evaporates.  A  sufficient  quantity  of  sterile  water  is  then  added 
to  make  the  strength  of  the  solution  required. 

Novocain  is  largely  replacing  cocain.  It  is  much  less  toxic 
and  can  be  sterilized  by  boiling. 

When  possible  the  blood  supply  of  the  part  should  be  arrested 
in  order  to  maintain  the  local  anesthetic  effect.  This  is  accom- 
plished in  the  case  of  the  extremities  by  means  of  an  Esmarch 
constrictor;  in  case  of  the  fingers  or  toes  by  constricting  the  base 
of  the  member  with  a  small  rubber  elastic  catheter. 

Following  the  usual  aseptic  preparations  a  hypodermic 
syringe  is  filled  with  the  required  solution  and  the  needle  attached. 
The  strength  of  solution  required  for  skin  incisions  is  usually 
1  per  cent.;  for  deeper  dissections  1/2  per  cent.  For  anesthetiz- 
ing nerve  trunks  a  few  drops  of  a  2  or  4  per  cent,  solution  is  used. 
In  eye  operations  the  lids  are  everted  and  a  few  drops  of  4  per 
cent,  solution  allowed  to  flow  over  the  conjunctiva. 

In  anesthetizing  the  skin  by  the  infiltration  method,  the  needle 
is  introduced  into  the  substance  of  the  skin  and  a  few  drops  of 
the  solution  injected — enough  to  raise  a  white  wheal.  The 
needle  is  then  pushed  farther  along  the  proposed  line  of  incision, 
still  in  the  substance  of  the  skin,  and  a  second  wheal  raised  which 
overlaps  the  first.  This  process  is  repeated  until  the  entire  line 
of  the  proposed  incision  has  been  anesthetized,  it  being  necessary 
to  withdraw  and  reinsert  the  needle  several  times.  The  skin  is 
tested  for  anesthesia  with  the  point  of  the  knife,  and,  as  soon  as 
this  is  established,  usually  in  less  than  two  minutes,  the  skin 
incision  is  made.  In  deeper  dissection  injections  of  1/2  per  cent, 
solution  may  be  made  into  the  surrounding  tissue,  or,  as  in  hernia 
operations,  the  main  nerve  trunk  supplying  the  parts  may  be 
anesthetized.  In  extensive  dissections  the  injection  of  1/6  to 
1/4  grain  morphin  sulphate  is  made  a  half  hour  before  the  opera- 
tion. As  the  period  of  anesthesia  is  variable,  it  is  well  to  proceed 
with  the  operation  as  speedily  as  possible.     The  amount  of  cocain 


158 


OPERATING    ROOM    AND    THE    PATIENT 


employed  should  be  noted  and  not  more  than  1  grain  be  injected 
into  tissues  in  which  the  blood  supply  is  not  under  control. 
Rarely  is  it  necessary  to  use  this  amount.  In  operations  in  which 
constriction  is  employed,  the  constriction  should  be  intermittently 
removed  at  the  close  of  the  operation  in  order  to  avoid  throwing 
a  large  amount  of  cocain  rapidly  into  the  general  circulation. 


Fig.   118. — Sylvester's  method  of  artificial  respiration  (inspiration). 
(Fowler's  Surgery.) 


General  effects  from  the  cocain  will  be  noted.  The  patient 
talks  quite  freely.  Should  the  heart  action  be  quickened  and  the 
pupils  dilate,  caffein  and  strychnin  will  be  found  useful.  A  cup 
of  strong,  hot  coffee  often  makes  these  patients  quite  comfortable. 

Artificial  Respiration. — ^This  is  employed  more  frequently 
for  the  restoration  of  patients  suffering  from  dangerous  surgical 
narcosis  than  in  any  other  connection.  It  should  be  commenced 
as  soon  as  respiration  actually  ceases,  as  shown  by  the  absence 


ANESTHESIA 


159 


of  all  thoracic  arid  abdominal  movements,  the  absence  of  evi- 
dences of  air  passing  from  the  mouth  or  nose,  and  the  signs  of 
deepening  cyanosis. 

Sylvester's  Method. — ^The  head  and  neck  should  be  fully- 
extended,  the  former  hanging  over  the  end  of  the  table;  the 
tongue  is  well  drawn  forward  to  prevent  possible  obstruction  to 


Fig.  119. 


-Sylvester's  method  of  artificial  respiration  (expiration). 
(Fowler's  Surgery.) 


the  entrance  of  air.  The  arms  are  grasped  at  the  elbows  and 
pressed  firmly  for  about  two  seconds  against  the  sides  of  the 
chest  (Fig.  119).  If  this  does  not  cause  an  expiration,  the 
pressure  should  be  made  below  the  costal  margins  in  the  direction 
of  the  diaphragm.  The  arms  are  now  brought  upward  to  each 
side  of  the  head,  inspiration  being  effected  by  thus  increasing 
the  capacity  of  the  chest  through  the  action  of  the  pectoral  mus- 
cles on  the  upper  ribs  (Fig.  118).     These  movements  are  kept 


160  OPERATING    ROOM    AND    THE    PATIENT 

up  at  the  rate  of  about  fifteen  times  a  minute.  With  the  occur- 
rence of  spontaneous  efforts  at  breathing,  care  must  be  taken 
to  supplement  rather  than  substitute  the  normal  respiration. 
The  artificial  movements  are  occasionally  suspended  in  order 
to  judge  of  the  efficiency  of  the  normal  efforts. 

Laborde's  method  of  rhythmic  traction  of  the  tongue  is  some- 
times successful  in  restoring  the  respiratory  reflex.  The  tongue 
is  grasped  by  forceps  and  alternate  traction  and  relaxation  made 
about  twent}"  times  a  minute.  This  is  kept  up  for  at  least 
half  an  hour,  unless  respiration  is  established  in  the  meanwhile. 
This  method  may  be  employed  alone  or  in  conjunction  with 
other  methods. 

Intralaryngeal  insufflation  consists  in  forcing  air  from  a  bel- 
lows into  the  lungs  through  an  intubation  attachment  (Fell- 
O'Dwyer  method).  Provision  is  made  for  the  escape  of  the 
expired  air  through  a  branch  tube.  A  modification  of  this 
apparatus  consists  of  the  substitution  of  a  graduated  pump  for 
the  bellow^s,  and  the  addition  of  a  mercurial  manometer  and 
automatic  cut-off  for  preventing  the  backward  leakage  of  air. 
This  improved  apparatus  is  also  arranged  for  administering 
oxygen  or  an  anesthetic  while  artificial  respiration  is  being 
carried  on  (Matas). 

Meltzer's  Method.^ — ^A  stomach  tube  is  introduced.  A  22 
French  catheter  is  inserted  into  the  pharynx  5  1/2  inches  from 
the  teeth.  The  tongue  is  pulled  forward  by  tongue  forceps.  A 
pad  one  inch  long  and  one  inch  thick  made  of  gauze  or  cotton 
is  placed  under  the  chin  on  the  suprahyoid  region  and  pressure 
made  on  it  by  a  handkerchief  tied  at  first  only  moderately 
firmly  over  the  head.  Pressure  on  this  pad  presses  the  middle 
part  of  the  tongue  against  the  posterior  part  of  the  hard  palate. 
The  bandage  should  be  tied  over  the  posterior  part  of  the  parietal 
bones.  A  weight  of  twelve  to  thirteen  pounds  is  placed  on  the 
abdomen.  Pressure  on  the  abdomen  offers  the  further  advantage 
that  it  drives  the  blood  from  the  abdomen  to  the  heart  and  brain 
and  the  medulla.  A  moderate  size  bellows  is  connected  with  the 
catheter  and  air  pumped  into  the  lungs.  Care  should  be  taken 
that  at  the  beginning  the  compression  should  not  be  made  too 

^  S.  J.  'Mehzei,  Journal  American  Medical  Association,  vol.  Iviii,  No.  19,  p.  1413. 


ANESTHESIA  161 

forcibly  and  rapidly,  not  oftener  than  ten  to  twelve  times  per 
minute.  If  each  compression  causes  only  a  slight  heaving  of 
the  chest,  the  bandage  over  the  head  should  be  tightened  and  if 
the  heaving  appears  too  strong  the  bandage  should  be  loosened 
accordingly.  Here,  as  in  the  method  of  intratracheal  insuffla- 
tion, too  much  pressure  and  careless  handling  may  do  harm. 
The  compression  should  never  be  made  so  tight  as  to  make  the 
escape  of  air  through  the  mouth  impossible  or  very  difficult. 

The  introduction  of  a  tube  into  the  stomach  permits  the 
handling  of  the  insufflation  with  greater  force,  more  efficiency 
and  greater  safety.  In  some  cases  the  use  of  the  stomach  tube 
might  be  even  indispensable,  when  for  one  reason  or  another, 
no  weight  can  be  placed  upon  the  abdomen.  The  stomach  tube 
should  not  be  too  small  in  diameter,  should  have  two  lateral  op- 
enings near  its  end  and  should  be  introduced  at  least  sixteen 
inches  from  the  teeth.  It  should  be  introduced  before  the  phar- 
yngeal tube.  There  is  no  objection  to  having  both  devices 
together,  the  stomach  tube  and  the  weight  on  the  stomach. 

The  insufflation  is  just  as  efficient  no  matter  what  position 
the  patient  is  in.  Instead  of  the  bellows  an  oxygen  tank  can 
be  utilized,  by  inserting  a  T  tube  in  the  connection  between 
the  oxygen  tank  and  the  catheter.  An  attendant  closes  and 
opens  the  vertical,  open  branch  of  the  T  tube  about  twelve 
times  per  minute;  the  closing  will  cause  inspiration  and  the 
opening  expiration.  The  closure  should  last  about  two  and  the 
opening  about  three  seconds.  In  order  to  prevent  too  much 
pressure  it  is  advisable  to  introduce  another  T  tube  which  should 
be  connected  with  a  safety  valve.  The  latter  is  prepared  in  the 
easiest  and  simplest  manner  by  having  mercury  in  a  double- 
necked  bottle  or  a  bottle  closed  with  a  stopper  having  two  per- 
forations. Through  one  of  these  openings  a  graded  tube  is 
introduced  and  submerged  about  15  to  20  mm.  under  the  sur- 
face of  the  mercury.  This  prevents  the  oxygen  entering  the 
pharynx  with  a  pressure  higher  than  15  or  20  mm.  of  mercury. 

The  Relation  of  Acapnia  to  Surgical  Shock. — Recent  studies  of 
the    English    physiologists^  have    demonstrated    the    intimate 

^  Haldane  and  Smith:     W.  H.  Howell,  Text-book  of  Physiology,  2nd  ed.,  p.  614.     Prof  • 
YandsJl  Henderson,  Johns  Hopkins  Bulletin,  vol.  xxl,  No.  233,  Aug.,  1910.     Amer.  Journ 
Phys  ,  vol.  xxiv,  April  1,  1909,  No.  1. 
11 


162  OPERATING    ROOM    AND    THE    PATIENT 

causative  relation  between  the  lowering  of  the  carbon  dioxid 
content  of  the  blood  and  the  condition  known  as  surgical  shock. 
This  lowered  carbon  dioxid  content  has  been  termed  "  acapnia, " 
smokelessness. 

Carbon  dioxide,  not  oxygen,  is  the  element  in  the  blood  upon 
which  direct  stimulation  of  the  respiratory  mechanism  depends; 
the  oxygen  may  vary  within  wide  limits,  other  things  being  equal, 
and  yet  have  no  material  influence  on  the  respiratory  mechanism 
so  far  as  its  efficiency  and  rapidity  of  functionation  is  concerned. 
In  similar  degree  is  the  general  venous  tone  regulated  by  the 
carbon  dioxid  content  of  the  blood  and  tissues,  and  overventila- 
tion  of  the  lungs  by  hj^perpnea,  or  rapid  respiratory  frequency, 
through  its  production  of  the  acapnic  state,  causes  not  only 
respiratory  collapse  but  also  that  circulatory  phenomenon  noted 
by  all  observers  on  shock,  autogenous  hemorrhage  or  venous 
stasis. 

In  surgery  the  factors  which  have  to  do  with  the  production 
of  the  acapnic  state  and  its  resultant  contributory  part  in  sur- 
gical shock,  are,  first  the  anesthesia  and  second  the  exposure  of 
large  surfaces  of  the  abdominal  viscera. 

The  excitant  stage  occurring  early  in  many  improperly 
exhibited  ether  anesthesias,  is  accompanied  by  varying  degrees 
of  hyperpnea  or  accelerated  respiratory  frequency.  This  accel- 
erated respiration  soon  overventilates  the  lungs  and  coinci- 
dently  lowers  the  carbon  dioxid  content  of  the  blood  and  tissues. 
At  the  same  moment — ^that  is,  the  moment  of  excitation  and 
hyperpnea,  the  dosage  of  the  anesthetic  agent  is  pushed  to  a 
maximum  by  the  anesthetist  anxious  to  subdue  the  struggling 
subject;  the  result  is,  that  simultaneously,  the  sensitiveness  of 
the  respiratory  mechanism  is  diminished  by  the  excessive 
dosage  of  narcotic  and  the  amount  of  natural  stimulant  to  that 
mechanism,  namely,  carbon  dioxid,  is  lowered.  These  two  con- 
ditions existing  at  the  same  moment  result  in  a  failure  of  respira- 
tion because  the  lowered  stimulant  cannot  reach  the  desensitized 
respiratory  mechanism.  The  threshold  of  the  respiratory 
function  is  elevated,  the  subject  is  coincidently  acapnic  and 
primary  respiratory  collapse  occurs. 

As  to  which  factor  plays  the  more  important  part  in  such 


PRE-OPERATIVE    PREPARATION    AND    THE    PRIMARY    DRESSING    163- 

anesthetic  respiratory  failure,  the  carbon  dioxid  starvation  or 
the  anesthetic  toxemia,  there  remains  much  yet  to  be  investigated 
and  proven.  Two  things,  however,  are  of  practical  value,  first, 
that  many  patients  die  early  in  the  narcosis  from  primary  res- 
piratory collapse,  which  may  be  prevented  if  the  acapnic  state 
is  kept  in  mind  and  warded  off,  and  second,  that  in  actual 
practice,  the  conservation  of  carbon  dioxid  early  in  a  narcosis, 
plus  the  careful  control  of  all  the  principles  of  what  Crile 
includes  in  his  heading  "  Anoci-association"  has  materially  les- 
sened the  accident  of  early  anesthesia  and  the  degree  of  anesthetic 
shock. 

The  second  factor  in  surgery  bearing  upon  the  occurrence 
of  acapnia,  is  the  exposure  of  viscera.  Professor  Henderson  after 
extensive  experimentation  has  concluded,'  that  from  the  serous 
surface  of  viscera  exposed  during  laparotomies  there  is  given 
off  carbon  dioxid  in  such  quantity  as  to  be  an  important  contrib- 
utory factor  in  the  production  of  acapnia 

The  anesthetic  plays  a  very  constant  and  serious  part  in  sur- 
gical shock  through  its  toxemia,  the  induction  of  circulatory 
disturbances  such  as  acapnia  and  loss  of  venous  tone,  respiratory 
collapse,  and  many  serious  sequelae.  The  rebreathing  of  modern 
anesthetic  technic  and  the  preliminary  use  of  sedative  hypoder- 
mic medication  are  among  the  practical  applications  of  the 
acapnic  theory  of  shock. 


CHAPTER  V. 


PRE-OPERATIVE  PREPARATION  AND  THE 
PRIMARY  DRESSING. 

General  considerations.  Examination  of  the  blood ;  heart ;  lungs ;  kidneys- 
Blood  pressure.  Skin.  Bowels.  Diet.  Local  preparation;  general  direc- 
tions; head;  neck;  thorax;  abdomen;  pelvis;  extremities.  Mouth  and 
associated  cavities.  Preparation  for  cleft  palate  operations.  Esophagus 
and  stomach.  Esophageal  diverticula.  The  small  and  large  intestine. 
Rectum  and  anus.  Urinary  system.  Preparatory  to  operations  upon  the 
thyroid  gland.  Exophthalmic  cases.  Preparation  just  prior  to  anestheti- 
zation.    Position  of  the  patient.     Dependent  head  position;  extended  neck 

^  Amer.Journ.  Phys.,  vol.  xxiv,  No.  1. 


164  OPERATING    ROOM    AND    THE    PATIENT 

position;  position  for  operation  on  the  thyroid;  for  amputation  of  the  breast; 
for  thoracotomy;  for  operations  upon  the  upper  abdomen;  dorsal  position; 
Trendelenburg  position;  reversed  Trendelenburg  position.  Lithotomy 
position.  Exaggerated  lithotomy  position;  Sims'  position;  kidney  position; 
ventral  position;  knee-chest  position.  Final  preparation  of  the  field  of 
operation.     Hand   disinfection.     Application   of  dressings. 

The  general  preparation  of  the  patient  begins  from  the  time 
that  the  surgical  condition  is  recognized.  Patients  should  be 
treated  in  such  a  manner  as  to  maintain,  and  indeed  increase, 
their  confidence  in  a  successful  solution  of  their  trouble.  Any- 
thing tending  toward  discouragement  should  be  obviated.  As 
a  rule,  the  nearer  the  individual's  normal  manner  of  living  is 
imitated,  the  more  satisfactory  the  result.  If  the  patient  is  not 
ill  enough  to  be  confined  to  bed  it  is  well  for  him  to  walk  about, 
read,  go  to  the  toilet,  take  his  own  bath,  and  at  the  time  set  for 
the  operation  walk  to  the  operating  room.  By  so  doing  not 
only  is  the  patient's  mind  kept  active  but  especially  in  hospital 
work  a  not  inconsiderable  amount  of  nurse's  time  is  saved. 
Nervous  patients  should  be  insured  a  good  rest  the  night  prior 
to  the  operation  by  the  administration  of  a  sedative,  preferably 
a  combination  of  the  bromids.  Any  concomitant  disease  should 
receive  appropriate  treatment.  An  examination  of  the  blood 
should  be  made  in  all  cases  of  chronic  septic  conditions  as  well 
as  in  acute  infections,  hemorrhage  cases,  and  cases  presenting 
signs  of  anemia.  The  examination  should  consist  of  a  red-cell 
count,  a  white-cell  count,  a  differential  white-cell  count,  and  an 
estimation  of  the  percentage  of  hemoglobin.  Should  the  latter 
be  below  50  per  cent,  it  should  be  increased,  if  feasible,  before 
the  operation.  In  suspected  hemophiliacs  and  in  jaundiced 
patients,  the  coagulation  time  should  also  be  noted. 

An  examination  of  the  heart  and  lungs  is  made,  any  deviation 
from  the  normal  noted  and  proper  treatment  inaugurated. 

Kidneys. — Immediately  following  the  bath  the  patient  is 
asked  to  urinate.  Catheterization  in  females  should  only  be 
resorted  to  in  case  the  examination  of  the  first  specimen  is  made 
difficult  by  the  admixture  of  vaginal  discharge.  When  time 
allows,  the  total  quantity  passed  in  twenty-four  hours  is  saved 
and  a  sample  of  the  mixed  urine  analyzed.  In  the  event  of  the 
discovery    of    any    pathologic   condition,    suitable    treatment    is 


PRE-OPERATIVE    PREPARATION    AND    THE    PRIMARY    DRESSING    165 

inaugurated  and  subsequent  urinalyses  made  sufficiently  often 
to  note  the  progress  of  the  condition. 

Blood  Pressure. — ^The  blood  pressure  should  be  taken  as  a 
routine  measure  in  all  patients  presenting  evidence  of  arterio- 
sclerosis, and  where  high  blood  pressure  is  found  the  operation 
should  be  postponed  if  practical.  In  operations  of  great  mag- 
nitude involving  necessarily  a  great  amount  of  shock,  such  as 
operations  upon  the  central  nervous  system,  the  blood  pressure 
is  noted  before  the  operation  and  at  frequent,  two  minute, 
intervals  during  the  operation.  In  such  cases  operations  should 
be  so  planned  as  to  allow  of  discontinuance  when  the  blood 
pressure  falls. 

The  arterial  blood  pressure  should  be  determined  by  a  special 
apparatus  devised  for  this  purpose.  Of  these  the  Janeway  is 
one  of  the  most  practical  for  surgical  purposes.  In  emergency 
cases  with  low  blood  pressure  rapidly  diffusible  cardiac  stimu- 
lants by  hypodermic  and  intravenous  or  direct  transfusion  are 
indicated.  In  emergency  cases  with  high  blood  pressure  nitro- 
glycerin hypodermically  is  of  value.  In  cases  which  allow  of 
several  days  preparation,  suitable  treatment  by  administration 
of  nitrites  is  indicated  in  cases  with  abnormally  high  blood 
pressure. .  In  case  of  low  blood  pressure,  whenever  feasible,  the 
case  should  be  brought  to  as  nearly  a  normal  state  as  possible 
before  operating. 

Janeway  gives  the  normal  systolic  pressure  for  children  up 
to  two  years  as  75  to  90  mm.  of  mercury;  for  children  over  two 
years  90  to  110  mm.;  for  adults  100  to  130  mm.  The  pressure 
in  females  is  about  10  mm.  less  than  in  males.  As  age  advances, 
the  pressure  as  a  rule  becomes  higher,  as  high  as  145  mm.  not 
being  considered  abnormal.  The  diastolic  pressure  registers 
from  25  to  40  mm.  less  than  the  systolic.  For  ordinary  surgical 
purposes  the  determination  of  the  systolic  pressure  is  all  that 
is  necessary. 

Whatever  instrument  be  used,  it  is  essential  that  the  armlet  be 
broad,  as  the  narrow  armlets  record  a  higher  blood  pressure. 
The  personal  equation  of  the  observer  plays  an  important  role. 

Technic. — Janeway's  Portable  Sphygmomanometer^  (Fig.  120). 

'  The  Clinical  Study  of  Blood  Pressure,  Janeway,  1904. 


166 


OPEKATING    KOOM    AND    THE    PATIENT 


The  apparatus  consists  of  a  U-shaped  manometer  connected 
with  a  cistern.  The  upper  joint  of  the  manometer  tube  is 
removable,  making  the  instrument  portable.  The  illustration 
shows  rings  on  the  right-hand  portion  of  the  sliding  board  in 
which  this  removable  portion  of  the  manometer  tube  is  stored. 
The  open  end  of  the  U  is  closed  by  a  small  cork  (F) ;  the  other 
end  is  automatically  closed  when  the  case  is  shut  by  a  block 


Fig.  120. — Blood-pressure  apparatus.     (Janeway.) 

which  compresses  the  rubber  joint  (G).  The  scale  is  slid  down, 
the  Politzer  bag  (C)  removed  from  the  stop-cock  (E)  which  con- 
tains a  needle  valve  for  slow  release  of  pressure.  This  stop- 
cock is  allowed  to  slip  under  a  spring  (H)  as  the  case  closes. 
The  lid,  to  the  under  side  of  which  the  manometer  is  fastened,  is 
then  closed  by  dropping  the  catches  which  fasten  behind  and 
folding  down  the  hinge  at  the  left,  the  lower  end  of  the  lid  sliding 
back  in  a  groove.  The  box  when  closed  measures  10  1/4X 
4  5/8X1  7/8  inches  and  with  the  armlet  and  Politzer  bag  weighs 
2  1/2  pounds.     The  manometer  tube  has  a  caliber  of  3  mm.  and 


PRE-OPERATIVE    PREPARATION    AND    THE    PRIMARY    DRESSING    167 

all  connections  are  of  heavy  pressure  tubing.  The  armlet  (B) 
is  a  hollow  rubber  bag  12  cm.  wide  and  18  cm.  long  with  an 
outer  leather  cuff  15X33  cm.  This  is  fastened  by  two  straps 
with  friction  buckles.  The  needle  valve  is  easily  manipulated 
and  allows  for  gradual  or  sudden  lowering  of  the  pressure  as 
desired.     The  scale  is  graduated  empirically. 

Application. — ^The  armlet  is  buckled  on.  The  cuff  should 
be  adjusted  snugly;  too  loose  an  adjustment  results  in  too  small 
amplitude  of  pulsation.  The  outlet  tube  should  be  dii^ected 
anteriorly.  The  scale  is  set  with  the  zero  point  at  the  level  of 
the  two  mercury  columns.  The  removable  portion  of  the 
manometer  tube  is  secured  in  place.  The  radial  artery  is  pal- 
pated, inflation  of  the  arm  bag  is  made  by  the  Politzer  bag 
raising  the  pressure  until  the  pulse  is  obliterated,  then  releasing 
it  very  slowly  and  steadily  until  the  pulse  returns.  The  reading 
on  the  scale  gives  the  systolic  pressure.  In  cases  presenting 
extremely  low  tension  the  Politzer  may  not  be  large  enough  to 
force  sufficient  air  into  the  arm  bag  to  the  extent  of  obliteration 
of  the  pulse.  If  this  is  so,  the  stop-cock  (E)  is  closed  while  the 
Politzer  bag  refills,  then  while  squeezing  the  Politzer  bag  the 
stop-cock  is  slowly  opened.  In  this  manner  the  pressure  can 
be  carried  as  high  as  desired  when  the  stop-cock  is  closed.  With 
the  finger  on  the  pulse,  open  the  stop-cock  slowly  until  the  air 
begins  to  escape  through  the  needle  valve.  In  this  manner 
the  pressure  of  the  armlet  is  very  gradually  lowered  until  the 
return  of  the  pulse.  Then  carry  the  pressure  a  little  higher  and 
repeat.  After  the  pulse  is  again  detected  allow  the  pressure 
to  fall  5  or  10  mm.  at  a  time  until  the  lowest  point  of  maximum 
oscillation  of  the  manometer  column  is  determined.  Allow 
any  air  remaining  in  the  apparatus  to  escape  by  removing  the 
Politzer  bag.  The  precaution  must  be  observed  to  allow  time 
after  each  fall  in  pressure  for  the  mercury  to  recover  from  the 
procedure  before  comparing  its  oscillations  with  those  at  the 
previous  level.  If  the  drop  has  been  sudden  there  will  be  a 
rebound  of  the  mercury  which  will  make  the  first  pulsations 
abnormally  large.  At  least  ten  to  twenty  oscillations  should 
be  observed  at  each  level  to  obtain  an  average.  Janeway  thinks 
that  a  rough  approximation  should  be  made  by  allowing  the 


168  OPERATING    ROOM    AXD    THE    PATIENT 

blood  pressure  to  fall  10  mm.  at  a  time;  then,  after  releasing  all 
the  pressure  to  return  to  just  above  the  point  thus  determined 
and  make  a  careful  estimation  at  5  mm.  intervals.  When  the 
greatest  fluctuation  of  the  column  does  not  exceed  5  mm.  it  is 
not  possible  to  form  any  judgment  and  the  same  holds  good 
when  the  pulse  is  very  rapid. 

The  Skin. — A  hot  bath  is  taken  the  evening  before  the  opera- 
tion. The  entire  surface  of  the  body  is  A'igorously  scrubbed 
with  soapsuds  and  a  soft  brush.  Particular  attention  is  paid 
to  the  head,  axillae,  genitals,  anal  region,  hands  and  feet;  the 
finger  nails  and  toe  nails  are  cut  short,  and  the  subungual 
spaces  well  scrubbed.  Patients  too  ill  to  take  or  be  given  a  tub 
bath  have  a  sponge  bath. 

Bowels. — Thorough  catharsis  is  not  only  unnecessary  but 
harmful  as  it  dehydrates  the  patient.  After  the  use  of  calomel 
occult  blood  is  always  found  in  the  stools.  Magnesium  sulphate 
is  a  cardiac  depressant,  extracts  too  much  water  and  tends  to 
produce  later  post-operative  distention.  Of  all  cathartics, 
castor  oil  is  the  least  harmful.  Cases,  other  than  acute  infec- 
tions of  the  abdomen,  receive  two  ounces  of  castor  oil  in  an 
equal  amount  of  dark  beer  the  afternoon  before  the  operation. 
If  the  bowels  do  not  move  freely  an  enema  is  given  early  on  the 
morning  of  the  operation.  Castor  oil  dehydrates  the  patient 
much  less  than  the  older  method  of  giving  magnesium  sulphate. 
In  this  connection  it  must  be  remembered  that  in  more  than  6 
per  cent,  solution  magnesium  sulphate  may  act  as  a  poison  and 
that  certain  obscure  deaths  are  traceable  to  its  use.  In  emer- 
gency cases  the  oil  is  omitted,  and  a  large  soapsuds  enema  given 
immediately  following  the  bath. 

Diet. — The  diet  should  be  highly  nutritious,  rapidly  assimil- 
able, and  such  as  to  leave  the  minimum  residue  in  the  intestines. 
The  patient  should  be  encouraged  to  indulge  in  liberal  quanti- 
ties of  water  up  to  within  six  hours  of  the  time  set  for  the  opera- 
tion. In  emergency  cases  which  have  recently  partaken  of  a 
meal  the  stomach  should  be  washed  out.  Debilitated  patients 
should  receive  rectal  alimentation  every  six  hours  in  addition 
to  being  fed  by  the  stomach. 

Local  Preparation.     General  Directions. — The  afternoon  pre- 


PRE-OPERATIVE    PREPARATION    AND    THE    PRIMARY    DRESSING    169 

ceding  the  time  set  for  operating  the  skin  of  the  field  of  opera- 
tion is  shaved.  In  emergency  cases  this  is  done  just  preceding 
the  anesthetic. 

Head. — ^Preceding  operation  upon  the  brain  the  hair  of  the 
entire  head  is  shaved.  Preparatory  to  intracranial  operations 
requiring     localization     Kronlein's      cerebro-topographic    lines 


Fig.  121. — Kronlein's  craniocerebral  topographic  lines.  1,  1,  Baseline, 
passing  through  the  infraorbital  ridge  and  the  superior  border  of  the  auditory 
meatus;  2,  2,  superior  horizontal  line,  passing  through  the  supraorbital 
ridge  parallel  to  the  base  line;  3,  3,  anterior  vertical  line,  passing  from  the 
middle  of  the  zygomatic  arch  perpendicular  to  the  base  line;  4,  4,  middle 
vertical  line,  passing  from  the  head  of  the  inferior  maxilla  (immediately  in 
front  of  the  tragus)  perpendicular- to  the  base  line ;  5,  5,  posterior  vertical  line, 
passing  from  the  posterior  palpable  margin  of  the  mastoid  process  per- 
pendicular to  the  base  hue;  3,  6,  line  of  fissure  of  Rolando;  3,  7,  line  of  fissure 
of  Sylvius.  (Fowler's  Surgery.) 

should  be  drawn  with  an  anilin  pencil  on  the  shaved  scalp  in 
accordance  with  the  rules  shown  in  the  illustration  (Fig.  121). 
A  ready  method  of  locating  the  fissure  of  Rolando  is  as  follows 
(Fig.  122) :  (1)  Draw  a  line  from  the  glabella  to  the  inion  with  an 
anilin  pencil,  and  mark  a  point  half  an  inch  behind  the  midway 
point  of  this  line;  this  represents  the  commencement  of  the 


170 


OPERATIXG    ROOM    AXD    THE    PATIENT 


fissui'e;  (2)  select  a  piece  of  stiff  paper  or  light  cardboard  four 
inches  square,  fold  it  diagonally  on  the  line  AC,  bringing  the 
edge  AD  to  correspond  with  the  line  AC;  (3)  place  the  card  with 
the  point  A  at  the  commencement  of  the  fissure,  and  the  edge 
AB  on  the  middle  line,  when  the  folded  edge  AE  will  mark  the 
site  of  the  fissure  sufficiently  near  for  all  practical  purposes. 

Preparatory   to    intracranial    operations   the    blood    pressure 
should  be  noted  and  the  blood-pressure  apparatus  left  attached 

so  that  the  pressure  can  be 
noted  at  frequent  intervals 
during  the  operation.  Fall 
in  blood  pressure  calls  for  a 
discontinuance  of  the  opera- 
tive procedure. 

In  the  case  of  small  tumors 
or  wounds  of  the  scalp  it  is 
sufficient  to  remove  the  hair 
wide  of  the  site  of  opera- 
tion. The  hair  remaining  is 
cleansed  by  shampooing  w^ith 
soap  and  hot  water,  thor- 
oughly rinsed  in  cold  water, 
then  rubbed  with  alcohol 
and  bichlorid,  1  :  5000,  thoroughly  dried,  and  in  the  case  of 
females  protected  from  further  injury.  The  eyebrows  should 
not  be  shaved,  but  should  be  completely  disinfected.  In  opera- 
tions near  or  involving  the  mouth  or  nose,  the  beard  and  mus- 
tache should  be  removed.  The  ears  should  be  cleansed  and 
lightly  packed  with  sterile  cotton.  In  inflammations  of  the 
meninges  and  serous  c aunties  in  general  hexamethylenamin 
has  been  proved  to  have  an  inhibitory  action  on  the  growth 
of  bacteria  (Crane).  It  is  administered  in  five  to  seven  and  a 
haK  grain  doses,  preferably  combined  with  benzoate  of  soda,  10 
grains,  three  times  daily. 

To  prevent  hemorrhage  from  the  soft  parts  in  operations  upon 
the  skull  in  those  localities  which  allow  of  its  application  a  three- 
quarter  inch  flat  rubber  tubing  of  sufficient  length  to  encircle 
the  head  is  used  as  a  tourniquet.     This  is  tightly  applied  and 


Fig.  122. — ^Chiene's  de\ace  for  locat- 
ing the  fissure  of  Rolando  (reduced 
size).      (Fowler's  Surger}'.) 


PRE-OPERATIVE    PREPARATION    AND    THE    PRIMARY    DRESSING    171 

secured  by  a  clamp  or  tape.  Its  posterior  part  lies  below  the 
inion,  its  anterior  at  the  glabella;  laterally  it  rests  just  above  the 
ears,  A  tape  fastened  antero-posteriorly  in  the  middle  line 
keeps  the  tubing  from  descending  too  far  and  pressing  on  the 
eyes  (Gushing),  or  this  may  be  prevented  by  temporarily  sutur- 
ing the  tubing  in  place  (Bristow). 

Neck. — ^In  operations  in  this  region  the  hair  on  the  side  to  be 
operated  upon  is  shaved  to  above  the  level  of  the  ear.  The 
hair  is  shampooed  as  for  operations  upon  the  head.  The  ears 
are  cleansed  and  packed  with  sterile  cotton.  The  axillae  should 
be  carefully  disinfected,  as  it  is  here  that  the  bacillus  pyocyaneus 
has  its  habitat.  It  is  not,  however,  necessary  to  shave  the  axillae. 
The  shoulder  and  chest  should  be  included  in  the  preparation. 

Thorax. — Both  axillae  should  be  disinfected;  the  one  upon  the 
side  to  be  operated  upon  should  be  shaved.  The  arm  upon  this 
side  should  be  included  in  the  preparation,  as  well  as  the  shoulder 
and  upper  part  of  the  abdomen. 

Abdomen. — ^The  cleansing  should  extend  from  the  nipples 
to  the  middle  third  of  the  thighs  and  as  far  back  as  the  post- 
axillary  line. 

Pelvis. — ^The  preparation  should  include  the  lower  abdomen 
and  upper  third  of  the  thighs,  as  well  as  the  external  genitalia, 
perineum  and  buttocks.  In  males  the  prepuce  should  be  care- 
fully cleaned  and  in  females  the  clitoris.  In  operations  involv- 
ing the  vagina,  as  well  as  in  laparotomy  cases,  the  vaginal 
mucous  membrane  is  cleaned  by  douching  twice  or  thrice  daily 
with  hot  boric  acid  solution.  In  septic  conditions  this  is  preceded 
by  a  1 :  2000  bichlorid  douche. 

Extremities. — ^In  operations  upon  the  arm  the  axilla  and 
shoulder  should  be  included  in  the  preparation;  in  the  case  of 
the  thigh  the  genitalia  and  hip  should  be  included.  In  opera- 
tions upon  joints  the  entire  extremity  should  be  prepared.  The 
preparation  of  the  hands  and  feet  is  part  of  the  general  prepara- 
tion of  the  patient.  Areas  such  as  the  elbow,  knee,  and  sole  of 
the  foot  should  receive  more  careful  attention  than  areas  where 
the  skin  is  not  so  thick.  Over  these  areas  borosalicylic  com- 
presses should  be  applied  and  renewed  every  four  hours,  the 
loosened  epithelium  being  removed  by  sponging  with  alcohol. 


172  OPERATING  ROOM  AND  THE  PATIEXT 

Mouth  and  Associated  Cavities. — Preceding  all  operations 
upon  the  mouth  and  associated  cavities  the  condition  of  the 
teeth  should  be  investigated  and  made  as  perfect  as  possible. 
The  teeth  should  be  cleansed  with  a  brush  after  each  meal,  and 
in  addition  an  astringent  and  antisej^tic  mouth-wash  and  nasal 
douche  should  be  emjaloj'ed  every  three  hours.  Minute  doses 
of  morphin  and  atropin  are  valuable  in  controlling  excessive 
secretion.  Ulcerative  conditions  such  as  are  present  in  car- 
cinoma of  the  tongue  should  be  treated  by  lightly  touching 
them  with  5  per  cent,  zinc  chlorid  solution  or  10  i^er  cent,  chronic 
acid  solution. 

Preparation  for  Cleft  Palate  Operation. — ^In  infants  the  nutri- 
tion should  be  improved  by  giving  liquid  food  every  two  hours 
for  a  week  or  ten  days  before  the  operation.  The  quantit}^  should 
be  gauged  to  prevent  stomach  regurgitation.  The  feeding 
bottle  should  be  provided  with  a  shield  which  will  cover  the 
defect  in  the  palate  and  prevent  for  the  most  part  regurgitation 
through  the  nose.  The  mouth  and  pharynx  should  be  examined 
and  any  septic  condition  as  aphtha  or  any  catarrhal  condition 
as  chronic  pharyngitis  due  to  the  manner  of  breathing  be  treated. 
Ulcerative  conditions  must  be  cured  before  operation.  Inflam- 
mation of  the  phar5mx  and  nose  should  be  treated  and  the 
mucous  membrane  brought  to  as  near  normal  condition  as  possi- 
ble. Adenoid  groMhs  in  the  naso-pharynx  and  enlarged  tonsils 
should  be  removed  preliminary  to  the  operation;  otherwise,  not 
only  would  the  operation  be  more  difficult  but  its  success  will 
be  doubtful  as  the  secretions  of  the  naso-pharynx  would  not 
have  a  readj'  exit  and  would  very  readily  infect  the  plastic  flaps 
formed  at  the  operation;  also  breathing  would  be  difficult.  Xo 
food  should  be  given  for  six  hours  previous  to  the  operation. 

The  Esophagus  and  Stomach.  Esophageal  Diverticula. — 
Preparatory  to  anesthesia  the  sac  should  be  emptied,  otherwise 
in  manipulating  the  sac  during  the  operation  its  contents  are 
expressed  into  the  pharynx  and  aspiration  pneumonia  may 
ensue  (Mayo).  If  the  patient  is  much  emaciated  operation  is 
postponed  and  feeding  by  tubo  instituted  until  a  more  favorable 
condition  of  the  patient  results.  This  is  readily  accomplished 
by  the  method  devised  by  Plummer  as  a  means  of  diagnosis  in 


PRE-OPERATIVE    PREPARATION    AND    THE    PRIMARY    DRESSING    173 

these  cases.  The  patient  swallows  three  yards  of  buttonhole 
silk  twist  and  ten  or  twelve  hours  later  three  yards  more  of  the 
continuous  thread.  If  there  is  an  opening  out  of  the  diverticu- 
lum the  thread  will  finally  find  its  way  into  the  stomach  and 
sufficiently  far  into  the  intestine  to  resist  removal  by  traction. 
Upon  this  as  a  guide  the  stomach  tube  is  passed.  Stomach. — 
If  there  is  interference  with  the  motor  function  the  stomach 
should  be  washed  out  shortly  before  the  operation.  The  washing 
should  continue  until  the  fluid  returns  clear,  when  the  remainder 
should  be  siphoned  out,  leaving  the  stomach  empty. 

The  Small  and  the  Large  Intestine. — The  most  we  can  hope 
to  accomplish  is  a  diminution  in  the  number  of  bacteria  which 
here  normally  find  their  habitat.  This  is  best  accomplished  by 
the  ingestion  of  sterile  food  leaving  the  smallest  residue  and 
frequent  cleansing  irrigation  of  the  mouth  and  nose.  In  the 
case  of  the  large  intestine,  Strassberger  has  shown  the  bac- 
terial content  to  be  60  per  cent,  normally.  This  is  decreased ' 
in  constipation,  increased  in  diarrhea.  Thorough  purgation  is 
therefore  contraindicated.  Sterilized  feeding  and  repeated  colon 
irrigations  for  several  days  preceding  the  operation  is  sufficient. 

Rectum  and  Anus. — The  preparation  includes  the  perineum, 
buttocks,  genitalia  and  upper  third  of  the  thigh.  Colonic  irri- 
gations should  be  given  the  evening  before  and  early  in  the 
morning,  at  least  six  hours  before  the  time  set  for  the 
operation. 

The  Urinary  System. — The  functional  activity  of  the  kidneys 
is  increased  by  forcing  fluids.  This  flushes  out  the  urinary 
tract.  In  operations  involving  the  bladder  and  in  those  in  which 
a  septic  condition  of  the  urine  exists  the  bladder  is  washed  out 
with  boric  acid  solution.  An  ounce  or  two  of  the  latter  may  be 
left  in  the  bladder.  Urotropin  several  times  daily  with  sodium 
benzoate  is  useful  in  septic  conditions.  In  operations  involving 
the  urethra,  should  septic  conditions  be  present,  thorough  irriga- 
tion through  a  small  catheter  with  boric  acid  solution  should  be 
done.  Cases  for  prostatectomy  with  much  residual  urine 
should  be  regularly  catheterized  every  six  hours  for  a  week  or 
ten  days  before  the  operation  in  order  to  avoid  renal  con- 
gestion from  too  rapid  relief  of  pressure  at  the  operation. 


174 


OPERATIXG  ROOM  AXD  THE  PATIEXT 


Preparatory  to  Operations  upon  the  Thyroid  Gland. — Goiters 
not  presenting  symptoms  of  hyperthyi'oidism  are  prepared  as 
for  any  operation.  Morphin,  gr.  1/4,  combined  with  atropin, 
gr.   1   120,  is  administered  hypodermically  one-half  liour  before 

the  operation  is  to  begin.  In 
cases  in  which  anesthesia  is  em- 
ployed the  preparation  of  the 
field  of  operation  should  be 
done  previous  to  beginning  the 
anesthesia.  In  cases  with  scah- 
hard  trachea  the  head  and  neck 
should  be  maintained  in  the 
position  in  which  the  patient 
breathes  easiest. 

Exophthalmic  cases  and  those 
goiters  of  other  types  which 
present  or  have  presented 
SA^mptoms  of  over-activit}'  of 
the  gland  are  specially  prepared 
by  conserving  the  water  in  the 
tissues.  For  this  reason  cathar- 
tics are  contraindicated  and  for 
several  days  before  the  opera- 
tion a  large  amount  of  water 
should  be  ingested.  On  the 
evening  before  and  on  the  morn- 
ing of  operation  a  colon  irriga- 
tion is  given.  Patients  who 
have  had  the  slightest  dilatation 
of  the  heart  should  not  be  pre- 
pared for  general  but  for  local 
anesthesia  for  the  reason  that 
even  in  the  hands  of  the  most 
skillful  anesthetist  the  slight 
accumulation  of  mucus  in  the  bronchi  may  prove  too  much 
strain  on  the  already  dilated  heart.  Iodine  should  not  be  used 
on  the  skin  as  its  absorbtion  may  cause  increase  of  h^'perthy- 
roidism.     For  the  same  reason  antiseptics  should  not  be  used  at 


PRE-OPERATIVE    PREPARATION    AND    THE    PRIMARY    DRESSING    175 

the  operation.     Operation  should  not  be  undertaken  during  an 
exacerbation  of  the  disease. 

Preparation  Just  Prior  to  Anesthetization. — A  freshly  laun- 
dered, light  flannel  night  shirt,  open  in  the  back,  is  put  on  the 
patient;  also  a  cap  or  bandage  to  confine  and  protect  the  hair, 
and  long  stockings  (Fig.  123).  If  the  patient  is  unable  to  urinate 
catheterization  is  employed  should  the  operation  involve  the 
pelvis,  otherwise  catheterization  may  be  omitted.  Those  cases 
not  urinating  voluntarily  or  not  catheterized  should  be  watched 
for  distention  of  the  bladder.  Routine  pre-anesthetic  stimula- 
tion is  unnecessary.  In  all  patients  save  children,  the  very  old, 
the  septic  or  the  anemic  one-eighth  of  a  grain  of  morphin  sul- 
phate with  one  two  hundred  and  fiftieth  of  atropin  sulphate  is 
given  hypodermically  one  hour  before  the  time  set  for  the  opera- 
tion. If  the  full  effect  is  not  noticeable  in  forty-five  minutes 
the  dose  is  repeated. 

The  position  of  the  patient  on  the  operating  table  varies 
according  to  the  nature  of  the  operation.  It  should  be  such  as 
will  render  the  part's  involved  prominent  and  easy  of  access 
and  yet  such  as  not  to  interfere  with  respiration  or  circulation. 
There  must  be  no  pressure  on  important  nerves.  The  position 
should  be  as  natural  as  possible.  The  pad  under  the  patient 
should  be  sufficiently  thick  and  soft  to  adapt  itself  to  the  patient's 
body.  If  the  lumbo-sacral  curve  is  more  pronounced  than  nor- 
mal a  rubber  pillow  is  placed  under  the  body  at  this  point. 
If  these  directions  are  disregarded  backache  will  follow.  The 
musculo-spiral  nerve  is  the  one  most  frequently  injured  through 
allowing  the  arm  to  rest  against  the  edge  of  the  table.  It  has 
been  caused  by  an  assistant  leaning  against  the  arm.  As  the 
anesthetic  is  started  the  patient  is  secured  in  the  required  posi- 
tion and  the  local  cleansing  begun.  For  most  positions  the  limbs 
may  be  secured  to  the  table  by  fastening  a  broad  strap  just 
above  the  knees.  The  arms  are  fastened  by  passing  each  into 
either  end  of  a  long  sleeve  in  which  the  patient  interlaces  his 
fingers  and  are  surrounded  by  a  thick  broad  soft  bandage  the 
ends  of  which  are  secured  to  the  table  (Fig.  113). 

The  dependent  head  position  (Fig.  124)  is  used  in  operations 
upon  the  mouth  and  nose.     Its  object  is  to  prevent  the  entrance 


176 


OPERATING    ROOM    AND    THE    PATIENT 


of  blood  into  the  larynx.  The  patient  lies  in  the  dorsal  posi- 
tion, arms  by  the  side,  with  the  head  hanging  over  the  end  of  the 
table.  The  back  of  the  neck  is  protected  by  placing  under  it  a 
small  flat  pad.     The  vertex  of  the  head  may  be  supported  by 


Fig.  124. — Dependent  head  position. 

the  hand  of  an  assistant.  The  position  may  be  combined  with 
the  Trendelenburg  posture,  the  head  of  the  patient  resting  in  the 
operator's  lap. 

The  extended  neck  position  (Fig.  125)  is  produced  by  placing 


Fig.  125. — Extended  neck  position. 

the  patient  in  the  dorsal  position,  hands  fastened  across  the 
epigastrium,  with  a  flat  sand-bag  beneath  the  shoulders.  The 
sand-bag  should  be  of  such  thickness  as  will  allow  the  head  to 
rest  on  the  table  without  excessive  extension  of  the  neck.     This 


PRE-OPERATIVE    PREPARATION    AND    THE    PRIMARY    DRESSING    177 

position   is   used   in   operations  upon  the   anterior   and  lateral 
regions  of  the  neck. 

Position  for  Operations  on  the  Thyroid  Gland. — ^The  patient 


Fig.  126. — Position  for  amputation  of  breast.     A  pad  siiould  be  placed 
underneath  the  elbow  to  protect  against  pressure. 


Fig.   127. — Thoracotomy  position. 


is  placed  in  the  extended  neck  position,  employing  the  Hartley 
head  rest  before  anesthesia  is  commenced.  The  position 
must    be    such    as    to  allow  free  respiration.     The  hands  are 

12 


178  OPERATING    ROOM    AND    THE    PATIENT 

bandaged    together    while    clasped    over   the  epigastrium  and 
the  ends  of  the  bandage  fastened  to  the  restraining  strap  secur- 


Fig.   128. — Position  for  resecting  the  ribs  in  pleurectomy. 
(Fowler's  Surgery.) 

ing  the  lower  limbs.     As  soon  as  anesthesia  is  established  the 
head  of  the  table  is  raised  in  order  to  lessen  hemorrhage.     Fre- 


Fig.   129. — Position  for  operations  upon  the  upper  abdomen. 


quently    it    happens   that   very   little    additional    anesthesia   is 
required  when  this  elevation  is  used.     It  is  an  advantage  to  have 


PRE-OPERATIVE    PREPARATION    AND    THE    PRIMARY    DRESSING    179 


the  anesthetist  out  of  the  way  and  for  this  reason  vapor  anes- 
thesia is  especially  desirable. 

The  position  for  amputation  of  the  breast  (Fig.  126)  is  the 
dorsal  position  with  a  flat  sand-bag  under  the  thorax  on  the 
affected  side.  The  patient  lies 
near  the  edge  of  the  table  on 
that  side.  The  arm  of  the  af- 
fected side  is  flexed  at  the  elbow, 
abducted  to  a  right  angle  at  the 
shoulder,  and  held  in  that  posi- 
tion by  bandaging  the  wrist 
loosely  to  the  table  or  is  held 
by  a  nurse.  The  other  hand 
lies  close  to  the  patient's  side. 
The  patient's  face  is  turned 
away  from  the  affected  side  so 
that  the  administration  of  the 
anesthetic  will  not  interfere  with 
the  operator.  Before  the  intro- 
duction of  the  sutures  the  arm 
is  brought  to  the  side  in  order  to 
secure  proper  approximation  of 
the  skin  flaps. 

The  position  for  thoracot- 
omy (Fig.  127)  is  similar  to 
the  above  except  that  a  larger 
sand  bag  is  used  and  the 
lateral  chest  wall  more  ex- 
posed by  allowing  the  arm  of 
the  affected  side  to  lie  across 
the  chest.  For  more  extensive 
operations  the  patient  is  placed 
more  nearly  on  the  side  (Fig. 
128). 

The  position  for  operations  upon  the  upper  abdomen  is  the 
dorsal  position  or  the  dorsal  position  with  a  moderately  large 
sand-bag  under  the  dorsal  spine,  or  the  position  is  secured  by 
using  the  apparatus  on  most  operating  tables  to  make  the  upper 


180 


OPERATING    ROO:\I    AND    THE    PATIEXT 


abdomen  prominent.  The  arms  may  be  placed  above  the  head 
(Fig.  129)  or  secured  high  up  across  the  chest.  Before  intro- 
ducing the  sutures  the  elevator  is  lowered  to  obviate  tension  on 
the  wound. 

The  dorsal  position  (Fig.  130)  is  "^-ith  the  patient  fiat  on  the 
back.     The  arms  may  be  either  secured  high  up  on  the  chest 
fastened  naturally  above  the  head,  or  allowed  to  rest  at  the  side. 

The  Trendelenburg  position   (Fig.  131)  is  secured  by  placing 
the  patient  in  the  dorsal  position,  with  the  shoulders  resting 


Fig.   131. — Trendelenburg  position. 


against  the  shoulder  supports  of  the  table.  The  head  of  the 
table  is  then  depressed  as  much  as  required.  In  intrapelvic 
operations  the  Trendelenburg  position  is  useful.  The  weight 
of  the  body  rests  on  the  shoulders.  To  prevent  pressure  effects, 
rubber  pads  are  placed  between  the  shoulders  and  the  supports. 

The  reversed  Trendelenburg  position  (Fig.  132)  is  useful  in 
operations  for  varicocele,  varicosities  of  the  lower  extremity,  in 
limiting  infection  to  the  lower  abdomen  in  diffuse  septic  peri- 
tonitis and  in  operations  on  the  head  and  neck.  The  patient 
is  secured  to  the  table  by  bandages  arranged  to  distribute  the 
strain,  the  feet  resting  against  a  padded  foot  piece. 

The  lithotomy  position   (Fig.   133)  is  obtained  by  placing  the 


PRE-OPERATIVE    PREPARATION    AND    THE    PRIMARY    DRESSING     181 

patient  in  the  dorsal  position  with  the  thighs  flexed  on  the 
abdomen  and  the  legs  on  the  thighs.  The  patient  should  then 
be  drawn  down  on  the  table  until  the  buttocks  project  well  over 
the  edge.  The  position  may  be  maintained  by  a  sling  sheet 
(Fig.  134).  To  accomplish  this,  a  large  sheet  is  folded  diago- 
nally and  placed  with  the  apex  hanging  over  the  foot  of  the  table. 
The  patient  is  then  placed  on  the  table  in  the  lithotomy  position, 
with  the  shoulders  resting  upon  the  upper  folded  portion  of  the 
sheet.     Each  lateral  corner  of  the  sheet  is  then  passed  around 


Icnburg  position. 


the  thigh  from  the  outside  and  drawn  taut.  One  end  is  then 
passed  back  of  the  neck  and  secured  by  knotting  to  the  other 
end.  A  more  secure  position  is  obtained  by  using  the  foot- 
holders  and  lithotomy  posts.  Care  should  be  taken  not  to  over- 
flex  the  thighs  nor  to  allow  the  inside  of  the  legs  to  be  pressed 
tightly  against  the  posts. 

The  exaggerated  lithotomy  position  (Fig.  135)  is  similar  to 
the  above  except  that  the  pelvis  is  elevated  either  by  placing  a 
large  flat  sand-bag  beneath  the  buttocks  or  by  combining  with 
the  Trendelenburg  position.     In  the  latter  event,  the  shoulder 


182 


OPERATING    ROOM    AXD    THE    PATIEXT 


Fig.  133. — Lithotomy  position. 


\^ 


i\ 


Fig.   134. — Lithotomy  position,  w-ith  sUng  sheet. 


PRE-OPERATIVE    PREPARATION    AND    THE    PRIMARY    DRESSING     183 

supports  should  be  so  placed  as  to  prevent  the  patient  from 
slipping  away  from  the  edge  of  the  table.  This  position  is  useful 
in  clean  vaginal  sections  to  aid  in  keeping  the  intestines  out  of 
the  pelvis,  in  rectal  operations  and  in  examination  of  the  female 
bladder. 

The  Sims'  position  (Fig.  136)  is  obtained  by  placing  the  patient 
upon  the  left  side,  the  left  side  of  the  face,  left  shoulder  and 


Fig.   135. — Exaggerated  lithotomy  position. 


breast  resting  upon  a  very  flat  pillow.  The  left  arm  lies  straight 
on  the  table  behind  the  patient.  The  right  arm,  bent  at  the 
elbow,  lies  naturally  across  the  chest.  The  buttocks  lie  near 
the  edge  of  the  table;  the  knees  are  flexed  and  drawn  up  toward 
the  abdomen,  the  right  knee  nearer  the  abdomen  than  the  left. 
A  small  pad  is  placed  between  the  knees. 

The  kidney  position  (Fig.  137)  is  secured  by  placing  the 
patient  in  Sims'  position,  either  upon  the  right  or  left  side,  as 
required;  then  introducing  an  oblong  sand  pillow  between  the 
table  and  the  flank  so  as  to  cause  the  kidney  region  on  the 


184 


OPERATING    ROOM    AXD    THE    PATIENT 


affected  side  to  become  prominent.  The  sandbag  should  be 
sufficiently  large  to  cause  a  flattening  of  the  affected  side  by- 
widening  the  space  between  the  ribs  and  the  iliac  crest.     The 


Fig.  136. — Sims'  position. 

kidney  attachment  to  the  operating  table  may  be  used  in  place 
of  the  sandbag.  The  patient  should  lie  more  upon  the  side 
than  in  the  Sims'  position.  This  is  maintained  by  a  second 
large   sandbag   placed  parallel  to  the  abdomen  or  by  securing 


Fig.   137. — single  kidney  position. 

the  patient  to  the  table  by   a  broad,   adhesive  plaster  strap 
crossing  the  body  above  the  level  of  the  ensiform. 

The  ventral  position   (Fig.  138)   is  flat  on  the  belly  with  the 
head  turned  to  one  side.     In  operating  upon  both  kidneys,  as 


PRE-OPERATIVE    PREPARATION    AND    THE    PRIMARY    DRESSING    185 

in  removal  of  the  capsule  or  double  suspension  operations,  this 
position  is  exaggerated  by  placing  a  large  sandbag  under  the 


Fig.  138. — Ventral  position. 

abdomen.     The  kidney  elevator  may  be  used  in  place  of  the 
sandbag.     The  arms  lie  at  the  side. 

The  knee-chest  position  (Fig.  139)  is  useful  in  direct  examina- 


Fig.  139. — Knee-chest  position. 

tions  of  the  rectum  and  the  bladder.  The  patient  kneels  upon 
the  table  and  with  the  thighs  at  right  angles  to  the  legs  inclines 
the  body  until  the  chest  rests  upon  a  rather  large  pillow,  the 


186 


OPERATING    EOOM    AND    THE    PATIENT 


head  being  turned  to  one  side;  the  arms,  flexed  at  the  elbow, 
help  to  support  the  body. 

Final  Preparation  of  the  Field  of  Operation. — An  assistant 
should  have  disinfected  his  hands  before  anesthesia  is  started. 
He  dons  two  pairs  of  gloves,  a  heavy  loose  pair  over  the  usual 
ones.  The  former  are  for  use  while  preparing  the  field  for 
operation  and  are  then  discarded.  He  should  have  on  cap, 
mask,  and  rubber  apron,  but  should  not  don  his  gown  until  he 
has  finished  preparing  the  patient.  As  the  anesthesia  is  started 
the  patient  is  placed  in  the  required  position.  Half  blankets 
are  arranged  smoothly  so  as  to  widely  expose  the  field  of  opera- 
tion and  the  area  to  be  disinfected  surrounded  with  sterile  towels 
(Fig.   140).     The  parts   are  then  carefully  scrubbed  for  three 


Fig.   140. — Dorsal  position;  ready  for  final  preparation. 


minutes  with  soap,  hot  water  and  sterile  gauze.  The  soapsuds 
are  sponged  away  with  sterile  water.  The  skin  is  sponged 
carefull}^  with  acid  bichlorid  (Harrington's  solution)  and  then 
dried  with  ether,  fresh  gauze  being  used  for  each  solution. 
The  area  beginning  at  the  line  of  incision  is  painted  with  tinc- 
ture of  iodin  on  a  stick  sponge.  The  skin  must  be  quite  dry 
before  the  iodin  is  applied.  If  the  preliminary  preparation  has 
been  thorough  it  is  only  necessary  to  paint  the  site  of  operation 
and  the  neighborhood  with  iodin.  Sinuses  are  disinfected  by 
curetting  and  packed  with  sterile  gauze.  In  abdominal  opera- 
tions in  the  female  no  more  than  the  ward  preparation  of  the 
vagina  is  necessary,  unless  a  preliminary  curettage  is  to  be  done. 
In  septic  endometritis  cases  a  bichlorid  douche  is  added  to  the 
repetition  of  the  usual  disinfection.  In  operations  upon  the 
bladder,  if  septic  conditions  be  present,  the  bladder  should  be 


PRE-OFERATIVE    PREPARATION    AND    THE    PRIMARY    DRESSING    187 


irrigated  with  boric  acid  solution.  In  operations  upon  the 
rectum  and  anus  the  sphincter  should  be  massaged  and  gradually 
dilated,  a  speculum  inserted,  and  the  rectum  washed  out  with 
saline.  During  dilatation  of  the  sphincter  the  anesthetic  should 
be  discontinued,  otherwise  a 
dangerous  depth  of  narcosis 
might  result.  Every  part  of 
the  patient. except  the  immedi- 
ate field  of  operation  should  be 
covered  with  sterile  protectors 
and  towels  held  in  place  by 
safety-pins  or  special  clamps 
(Fig.  141).  The  patient  should 
be  kept  dry  throughout  the 
preparation.  Solution  must 
not  be  allowed  to  wet  the  pa- 
tient except  over  the  area  to 
be  prepared. 

Hand  Disinfection. — It  is  of 
extreme  importance  that  all 
persons  coming  in  contact 
directly  or  indirectly  with  the 
operative  field  keep  their  hands 
always  in  a  healthy  and  cleanly 
condition.  Those  exposed  to 
septic  organisms,  as  dressers, 
must  wear  rubber  gloves  while 
doing  such  dressings.  Skin 
disinfection  has  for  its  object 
the  mechanic  removal  of  germs 
from  the  surface  of  the  skin, 
the  chemic  inhibition  of  germs 
which  are  brought  from  the 
depths  of  the  skin  to  the  sur- 
face by  the  sweat  and  sebaceous  glands,  and  the  mechanic  lessen- 
ing of  the  conditions  which  produce  sweating.  There  is  at  pres- 
ent no  method  by  which  these  aims  can  be  certainly  attained. 
A  hand  which  is  scrubbed  clean  mechanically  and  which  gives 


188  OPERATING    ROOM    AXD    THE    PATIEXT 

no  culture  -u-ill,  upon  being  moved  about  for  a  few  minutes,  give 
a  culture.  ^Yith  the  object  of  overcoming  the  conditions  present 
so  far  as  possible,  the  following  procedure  is  advocated: 

The  hands  and  forearms  are  first  vigorously  scrubbed  for 
five  minutes  with  soap  and  a  soft  brush  or  gauze  in  hot  running 
water.  The  hot  water  brings  to  the  surface  at  least  some  of 
the  bacteria  residing  in  the  depth  of  the  skin.  A'igorous  scrub- 
bing facilitates  this  and  removes  the  bacteria  from  the  surface. 
The  nails,  softened  by  the  hot  water,  are  then  trimmed  clown  to 
the  quick,  not  close  enough  to  be  painful,  but  close  enough  to 
obliterate  the  subungual  spaces.  For  those  who  object  to 
trimming  their  nails  so  short,  a  wire  nail  cleaner  is  recommended. 
The  hands  and  forearms  are  again  scrubbed  for  five  minutes. 
The  brush  must  not  be  so  stiff  or  used  so  vigorously  as  to  abrade 
the  skin;  so  doing  would  open  up  avenues  of  infection  quite 
needlesslj^.  The  lather  is  rinsed  off  freciuently.  The  hands 
are  finally  rinsed  in  1 :  3000  bichorid  of  mercury.  If  gloves 
are  to  be  worn  they  are  put  on  wet  in  the  bichlorid  solution;  if 
gloves  are  not  desired  the  hands  are  deeply  stained  in  a  hot 
bichlorid-permanganate  solution.  This  serves  three  purposes; 
the  permanganate  penetrates  the  skin  deeply,  and  so  carries 
the  bichlorid  into  the  depths  of  the  skin;  owing  to  its  astringencj^, 
it  contracts  the  tissues  and  so  tends  to  prevent  sweating;  in 
addition,  it  forms  a  film  on  the  surface  of  the  skin  and  so  tends 
to  prevent  the  entrance  as  well  as  the  egress  of  bacteria  from  the 
depth  of  the  skin.  Finally,  during  the  operation  at  intervals 
of  five  minutes  the  hands  should  be  rinsed  in  cold  bichlorid 
solution  1  :3000  or  1  :  4000  in  50  per  cent,  alcohol.  This  serves 
to  rinse  off  such  bacteria  as  work  out  from  the  depths  of  the  skin 
while  the  low  temperature  of  the  solution  and  the  alcohol  present 
tend  to  minimize  sweating.  In  cases  of  skin-grafting  and  plastic 
operations  saline  solutionis  used  for  the  hands  in  place  of  bichlo- 
rid solution. 

The  after-care  of  the  hands  is  important.  The  hands  are 
gently  scrubbed  in  hot  water  to  open  ixp  the  pores,  all  soap 
rinsed  off,  and  if  permanganate  has  been  used,  immersed  in  a 
hot  saturated  solution  of  oxalic  acid  to  remove  the  permanga- 
nate.    The  hands  are  rinsed  in  warm  water  and  then  in  cold 


PRE-OPERATIVE    PREPARATION    AND    THE    PRIMARY    DRESSING    189 


ammonia  solution,  one  ounce  of  ammonia  to  two  quarts  of  water 
to  neutralize  the  oxalic  acid.  If  a  little  green  soap  is  added 
the  hands  are  kept  white  and  soft.  If  the  hands  feel  dry,  lanolin 
may  be  rubbed  into  the  skin. 

Before  disinfecting  the  hands  and  forearms  a  cap,  mask  and 
rubber  apron  should  be  donned.  After  disinfection  is  complete 
a  sterile  gown  is  put  on. 

Application  of  Dressings. — ^The  skin  in  the  neighborhood  of 
the  wound  is  cleaned  with  hydrogen  peroxid,  then  saline  solu- 
tion and  dried.  Dry  sterile  'gauze  compresses  are  placed  next 
the  wound.  Adhesive  plaster  is  useful  to  retain  the  wound 
dressing.  If  drainage  tubes  have  been  used  the  gauze  is  built 
up  around  them  to  prevent  undue  pressure.  In  drainage  cases 
the  compresses  are  moistened  to  promote  drainage.  The  neigh- 
boring parts  are  then  dried  and  a  layer  of  absorbent  cotton 
covered  by  a  layer  of  nonabsorbent  is  placed  over 
the  wound  dressing.  In  other,  cases  a  single  layer 
of  nonabsorbent  cotton  is  used.  In  securing  band- 
ages with  pins  care  should  be  taken  not  to  wound 
the  skin.     In  moving  the  patient  strain  upon  the 


Fig.   142. — Volkmann's  posterior  leg  splint.      (Fowler's  Surgery.) 


sutures  must  be  avoided.  The  purpose  of  the  dressing  is  to 
relieve  strain  and  insure  rest  of  the  parts  as  well  as  to  pro- 
tect the  wound  against  infection.  Dead  spaces  should  be 
obliterated  by  pressure  of  the  dressing.  The  Volkmann  block 
or  an  inverted  basin  facilitates  the  application  of  dressings  to 
the  trunk.  Dressings  should  fit  smoothly  and  be  comfortable. 
Dressings  on  the  cervical  region  should  include  the  head, 
shoulder,  and  thorax.  Thorax  dressings  should  include  the 
shoulder  and  upper  abdomen.  Abdominal  dressings  should 
go  well  over  the  flanks,  thighs,  and  lower  part  of  the  thorax. 


190  OPERATING    ROOM    AND    THE    PATIENT 

Respiration,  however,  must  not  l^e  interfered  with.  In  apply- 
ing the  abdominal  binder  the  binder  should  be  rolled  up  half- 
way' lengthwise;  the  patient  should  be  rolled  partly  on  the  side 
and  the  rolled  portion  of  the  binder  placed  beneath;  by  rolling 
the  patient  ^^artially  in  the  other  direction  the  roUed-ujo  por- 
tion of  the  binder  can  be  grasped  and  unrolled.  The  binder  is 
pulled  taut.  It  should  extend  well  down  on  the  thighs  and 
well  up  on  the  lower  part  of  the  thorax,  and  should  fit  snugly. 
The  ends  are  folded  on  themselves  and  pinned,  the  one  over 
the  other  in  the  middle  line.  A  vertical  line  of  safety-pins  over 
each  flank  causes  the  binder  to  fit  more  closely  to  the  body. 
Two  perineal  straps  which  follow  the  gluteal  fold  keep  the 
binder  in  position.  Vulvar  and  perineal  dressings  are  retained 
in  position  by  T-bandages.  In  apph'ing  splints,  such  as  the 
Yolkmann  (Fig.  142),  to  the  lower  extremity  the  foot  should 
be  first  attached  in  the  desired  position  to  the  splint  before 
bandaging  the  rest  of  the  extremity. 


CHAPTER  AT. 


GENERAL  CONSIDERATIONS  IN  THE  AFTER- 
TREATMENT. 

General  considerations;  piirpose.  The  bed.  Position  of  the  patient. 
The  elevated  head  and  trunk  position.  Recovery  from  anesthesia.  Post- 
anesthetic vomiting.  General  appearance  of  the  patient.  Parotitis.  Pain. 
Backache.  Thirst.  Feeding.  Gavage.  Xasal  feeding.  Rectal  feeding. 
Sterile  feeding.  Subcutaneous  feeding.  Gastrostomy  feeding.  Jejunal 
feeding.  The  digestion.  Distention.  Intestinal  toxemia.  Fecal  impac- 
tion. Enemata  and  colon  irrigations.  Proctoclysis.  Singtdtus.  Dilata- 
tion of  the  stomach  and  duodenum.  The  general  rules  of  hygiene.  Urine. 
Albimiinuria.  Cj'stitis.  Anuria.  Retention  of  urine.  Catheterization  in 
the  female.  Catheterization  in  the  male.  Post-operative  pneumonia. 
Cupping.  Hydremia.  Temperature.  The  pulse.  Respiration.  Dehrium 
tremens.     Toxemia  following  operations.     Acidosis. 

General  Considerations. — A  successful  issue  in  many  cases 
depends  upon  the  care  which  is  exercised  in  the  after-treatment. 
The  operator's  responsibility  does  not  end  with  the  laying  down 
of  the  scalpel,  but  continues  until  healing  is  complete.  Many 
operative  procedures  would  be  absolutely  negatived  by  failure 


GENERAL    CONSIDERATIONS    IN    THE    AFTER-TREATMENT     191 

to  carry  out  the  proper  after-treatment.  Attention  to  detail 
insures  a  successful  outcome  while  its  neglect  has  lost  many  a 
patient  and  marred  many  a  reputation. 

The  purpose  of  the  after-treatment  is  to  recognize  complica- 
tions early  and  so  to  treat  them  as  to  give  the  patient  not  only 
the  best  chance  for  recovery,  but  also  the  best  final  functional 
result.  Not  only  must  the  wound  or  injury  itself  be  treated,  but 
the  entire  organism  must  be  brought  to  as  nearly  a  normal 
condition  as  possible.  Each  case  must  be  studied  as  regards 
habit  of  life  and  complicating  diseases  particularly  as  to  anemia, 
syphilis,  tuberculosis  and  diabetes.  The  working  of  every 
organ  must  be  known  in  order  to  treat  the  case  intelligently. 

Utensil  Sterilization. — It  is  important  that  not  only  should 
utensils  that  come  in  direct  or  indirect  contact  with  the  wound 
be  sterilized  but  also  that  such  utensils  as  bed  pans,  douche  pans, 
urinals,  etc.,  be  sterilized  after  each  use.  An  unsuspected 
specific  urethritis  or  vaginitis  may  otherwise  be  communicated. 
As  an  additional  precaution,  patients  with  communicable  dis- 
eases should  have  individual  utensils. 

The  bed  should  be  easily  separable  for  purposes  of  cleanliness. 
Enameled  iron  bedsteads  with  wire  springs  serve  admirably. 
They  have  the  advantage  of  being  cheap,  and  are  practically 
indestructible.     Felt  mattresses  are  preferable. 

Preparation  of  the  bed  for  the  reception  of  the  patient: 
The  bed  clothes  consist  of  a  thin  rubber  sheet  to  protect  the 
mattress,  two  sheets,  an  upper  and  an  under  one,  and  a  draw- 
sheet,  two  light  blankets,  a  counterpane,  and  a  small  pillow. 
Several  towels  and  a  basin  for  vomitus  are  so  placed  as  to  avoid 
soiling  of  the  clothing.  Hot-water  bottles  are  placed  between 
the  blankets  half  an  hour  before  the  return  of  the  patient  is 
expected.  Unless  the  patient  is  in  shock  these  are  removed 
when  the  patient  is  placed  in  bed;  if  not,  care  must  be  taken 
that  they  do  not  burn  the  patient. 

The  position  of  the  patient  will  depend  upon  the  character  of  the 
operation  and  upon  the  presence  of  shock  (Fig.  143).  During  the 
first  few  hours  shock  may  necessitate  the  Trendelenburg  posture 
except  in  diffuse  septic  peritonitis  cases.  In  uncomplicated 
cases  the  position  should  be  as  comfortable  as  compatible  with 


192 


OPERATING    ROOM    AXD    THE    PATIENT 


Fig.   143. — Bed  ready  u>  recL-ive  patient  in  shock. 


lig.  144. — Elevated  head  and  trunk  position.      (Fowler'j 
Surgery.) 


GENERAL    CONSIDERATIONS    IN    THE    AFTER-TREATMENT     193 

proper  rest  of  the  operated  part.  The  patient  may  be  placed 
on  one  side,  as  in  empyema  or  renal  operations;  or  the  elevated 
head  and  trunk  position  (Fig.  144)  is  employed  in  cases  of  diffuse 
peritonitis,  excessive  vomiting,  or  following  operations  upon 
the  upper  abdomen.  Except  in  scabbard  trachea  met  in  certain 
goiter  cases  the  head  may  be  in  such  position  as  the  patient 
wishes.  Following  herniotomy  or  abdominal  section  a  pillow 
under  the  knees  makes  the  patient  more  comfortable  by  relieving 
the  tension  on  the  abdominal  wall.  Sandbags  are  useful  to 
maintain  quiet  of  an  injured  member.  Should  extension  of  a 
limb  be  necessary,  boards  are  placed  beneath  the  mattress  to 
give  stability.  Pressure  from  bedclothes  is  avoided  by  frames 
which  keep  the  weight  of  the  bedclothes  from  the  body.  Bed- 
rests, rubber  rings  and  pillows  are  useful  in  maintaining  the 
patient  in  a  comfortable  position.  The  water  bed  is  necessary 
in  spinal  cases  or  in  much  debilitated  cases.  In  cases  in  which 
hemorrhage  or  oozing  is  feared,  the  parts  affected  should  be 
elevated  to  lessen  the  flow  of  blood  to  them.  Old  or  debilitated 
patients  should  have  the  shoulders  propped  up  and  their 
position  changed  frequently  in  order  to  avoid  hypostatic 
pneumonia. 

Elevated  Head  and  Trunk  Position. — There  is  normally  a  force 
in  the  peritoneal  cavity  which  carries  fluids  and  foreign  particles 
toward  the  diaphragm  regardless  of  posture,  though  gravity  may 
greatly  favor  or  retard  the  current.  To  further  the  force  of 
gravity  and  to  counteract  the  force  exerted  by  the  diaphragm 
in  attracting  infectious  material  to  its  own  neighborhood,  the 
plan  of  placing  the  patient  in  the  elevated  head  and  trunk  posi- 
tion, in  order  to  facilitate  the  passage  of  fluids  from  the  ab- 
dominal areas  to  the  pelvis,  is  believed  to  be  of  value.  The 
head  of  the  bed  is  raised  so  that  its  plane  is  from  twelve  to 
sixteen  inches  from  the  horizontal.  The  patient  is  prevented 
from  slipping  dow^n  in  the  bed  by  a  large  folded  pillow  placed 
beneath  the  flexed  knees  and  resting  against  the  thighs  and 
buttocks.  The  pillow  is  prevented  from  slipping  by  a  strong 
bandage  passed  through  the  folded  portion  and  secured  to  the 
frame  of  the  bed  at  its  sides  (Fig.  144).  The  elevated  head 
and  trunk  position  offers  the  additional  advantages  of  assisting 

13 


194  OPERATIXG    ROOM    AND    THE    PATIENT 

materially  in  relieving  the  nausea  and  vomiting,  and  of  favoring 
peristalsis  and  the  relief  of  distention  by  the  passage  of  flatus. 

The  stay  in  bed  should  be  as  short  as  is  compatible  with  wound 
rest.  If  wound  rest  can  be  maintained  with  the  patient  in  a 
chair  or  walking  about  this  is  preferable.  As  soon  as  possible 
the  patient  should  get  into  the  open  air  and  sunshine. 

Flat-foot  occasionally  develops  upon  again  walking  after  long- 
continued  nonuse.  The  essential  point  in  the  treatment  is  to 
compel  the  patient  to  walk  on  the  outer  side  of  the  foot,  supina- 
tion being  thus  encouraged.  To  effect  this  he  should  wear  a 
high  laced  shoe,  with  a  high  and  broad  heel  which  extends  well 
forward  to  the  site  of  the  articulation  between  the  os  calcis  and 
the  cuboid.  The  inner  side  of  this  heel,  and  the  sole  as  well, 
should  be  increased  at  least  a  half  inch  in  thickness.  At  the 
same  time  a  thin  steel  flap  or  inside  sole,  curved  to  fit  the  normal 
arch  (Whitman)  and  covered  with  gutta-percha,  is  to  be  worn 
inside  the  shoe  to  support  the  arch  (Fig.  145).     In  the  cases  in 


Fig.  145. — ^Miitman's  plate  to  support  the  arch  of  the  foot  in  flat-foot. 

(Fowler's  Surgery.) 

which  these  measures  fail  to  compel  the  patient  to  walk  on  the 
outer  side  of  the  foot,  the  application  of  an  internal  splint, 
jointed  at  the  ankle  and  extending  to  an  encircling  band  at  the 
knee,  will  assist  in  supinating  the  foot.  Massage  of  the  foot  and 
of  the  muscles  of  the  leg  should  not  be  neglected.  During  an 
acute  exacerbation  in  inflammatory  flat-foot  the  patient  should 
assume  the  recumbent  position,  when  supination  sometimes 
occurs  from  the  weight  of  the  foot.     After  a  rest  in  bed  of  from 


GENERAL    CONSIDERATIONS    IN    THE    AFTER-TREATMENT       195 

seven  to  fourteen  days  he  may  be  permitted  to  walk  with  a 
Whitman's  curved  steel  plate  in  the  shoe  to  support  the  arch. 

Recovery  from  Anesthesia. — ^The  patient  is  watched  until 
conscious.  Movements  tending  to  bring  strain  on  the  operated 
parts  should  be  restrained.  Too  vigorous  restraint  is  avoided 
as  it  causes  the  patient  to  struggle  harder.  In  case  of  violent 
patients  a  sheet  is  passed  over  the  thighs  and  another  over  the 
shoulders  and  fastened  to  the  sides  of  the  bed.  As  a  rule,  the 
less  the  minor  movements  of  the  extremities  are  interfered  with, 
the  more  tractable  the  patient  will  be. 

Post-anesthetic  Vomiting. — ^The  vomited  matter  is  watery 
and  usually  colorless.  It  consists  of  anesthetic-soaked  mucus 
and  stomach  secretions.  At  times,  it  may  present  a  brilliant 
green  appearance,  due  to  admixture  with  bile.  It  rarely  lasts 
longer  than  a  few  hours  and  need  cause  no  anxiety,  though  the 
patient  feels  wretchedly.  The  chief  danger  is  that  some  of  the 
vomitus  may  be  aspirated  into  the  bronchi  and  set  up  a  foreign- 
body  pneumonia.  Vomiting  is  prevented  to  a  great  extent  if 
proper  precautionary  measures  have  been  employed.  The  ele- 
vated head  and  trunk  position  tends  to  prevent  vomiting,  and 
promotes  the  passage  of  stomach  contents  into  the  intestine. 
To  allay  persistent  anesthetic  vomiting  lavage  is  practised. 
This,  if  done  early,  removes  the  anesthetic-soaked  secretions 
from  the  stomach  which  is  the  chief  cause  of  post-anesthetic 
vomiting.  Spraying  the  nose  and  throat  with  a  4  per  cent, 
solution  of  cocain  will  prove  useful  in  some  cases.  Frequently 
rinsing  the  mouth  with  cold  water  is  useful.  It  sometimes 
happens  that  vomiting  persists  for  several  days  or  in  neurotic 
patients  even  longer.  This,  when  not  traceable  to  other  causes 
(vicious  cycle,  obstruction,  dilatation  of  the  stomach)  must  be 
attributed  to  a  disturbed  motility  of  the  stomach  itself,  due  to 
nerve  disturbance.  The  character  of  the  vomitus  does  not 
differ  from  that  of  anesthetic  vomiting.  Thin,  mucous  secre- 
tions, partially  bile-stained,  are  vomited  frequently.  System- 
atic lavage  of  the  stomach  must  be  practised.  This  is  repeated 
at  intervals  of  four  hours  if  vomiting  persists.  Following  a 
thorough  cleansing  of  the  stomach,  one-fourth  grain  of  morphin 
with  gr.   1/120  of  atropin  sulphate,  is   administered   hypoder- 


196  OPERATING  ROOM  AXD  THE  PATIENT 

mically.  In  this  connection  it  is  well  to  remember  that  some 
persons  have  an  idiosyncrasy  to  morphin,  and  that  the  drug- 
may  cause  persistent  nausea  and  vomiting.  In  neurotic  indi- 
viduals the  use  of  counter-irritation  over  the  epigastrium  by 
means  of  a  mustard  plaster,  or  even  the  application  of  the  ther- 
mocautery, is  useful.  Nutrition  in  cases  of  persistent  vomiting 
is  maintained  by  nutrient  enemata.  Medication  by  the  mouth 
is  withheld  while  the  attacks  of  vomiting  continue.  When 
feeding  by  the  mouth  is  renewed,  half  ounce  doses  of  hot  fluids 
are  given  at  hour  intervals,  and,  if  these  are  retained,  the  amount 
is  gradually  increased  and  the  intervals  lengthened. 

General  Appearance  of  the  Patient. — To  an  experienced  eye 
the  picture  which  the  patient  presents  is  of  great  value.  In  an 
uncomplicated  case  the  facial  expression  will  be  contented  and 
the  patient  will  welcome  the  surgeon  with  a  smile.  There  may 
be  some  minor  complaints,  but,  on  the  whole,  the  picture  will 
be  a  happy  one.  Such  a  case  need  occasion  no  anxiet}'.  In 
abdominal  distention  the  countenance  is  somewhat  troubled. 
In  hemorrhage  the  face  is  colorless,  lips  waxy,  pupils  dilated, 
respiration  rapid  and  shallow,  the  skin  clammy,  and  the  patient 
thirsty,  anxious,  and  restless.  In  extensive  peritonitis  the  face 
is  drawn  and  anxious,  the  eyes  somewhat  sunken,  pupils  dilated, 
skin  covered  with  sweat,  and  the  patient  depressed;  later  restless- 
ness, both  mental  and  physical,  develop,  while  in  some  cases  a 
peculiar  dusky  suffusion  of  the  face  is  noted.  In  anuria,  in 
the  early  stages,  there  is  a  peculiar  glittering  of  the  eye  and  a 
suffusion  of  the  face  which  clinical  experience  readily  recognizes. 
Later,  the  picture  is  classic.  In  pneumonia  the  face  is  dusky 
and  the  respiration  rapid  and  labored  Parotitis  is  self-evident. 
It  will  repay  the  surgeon  to  make  a  careful  study  of  patients' 
faces.  Often  the  first  clue  to  a  serious  complication  may  be 
thus  furnished.  On  the  other  hand,  a  calm  face  and  air  of  gen- 
eral contentment  will  furnish  grounds  for  a  good  prognosis 
even  when  serious  complications  are  threatening. 

Parotitis. — This  is  an  infrequent  complication.  I  have  seen 
it  eight  times  following  laparotomy,  never  after  other  operations. 
In  four  cases  typical  symptoms  of  the  disease  presented  during 
the  second  week  following  operations  upon  the  adnexa.     Neither 


GENERAL    CONSIDERATIONS    IN    THE    AFTER-TREATMENT     197 

case  suppurated,  though  painful  swelling  persisted  for  several 
days.  In  one  case  the  disease  was  bilateral,  in  the  others  unilat- 
eral. In  a  fifth  case  the  disease  was  unilateral,  developing 
five  days  following  an  operation  for  extrauterine  pregnancy. 
In  the  sixth  case  the  disease  developed  eighteen  days  following 
an  operation  for  appendicitis  with  abscess.  Two  other  cases 
followed  operations  for  appendicitis  in  which  there  was  no  out- 
lying infection.  Another  case  occurred  as  a  complication  of 
appendicitis  which  was  not  operated  upon.  In  this  case  the 
infection  attacked  the  external  ear  and  rupture  of  the  lining  of 
the  external  auditory  canal  occurred.  Another  case  occurred 
in  a  patient  suffering  from  septicemia.  All  the  cases  were  in 
females  and  all  recovered. 

In  reported  cases  which  have  resulted  fatally  and  which  have 
been  submitted  to  microscopic  examination  the  cause  was  a 
catarrh  of  Stenson's  duct  following  infection  from  the  mouth. 
In  such  cases  the  prognosis  should  be  good.  The  lesion,  however, 
may  be  one  of'  many  resulting  from  a  profound  septic  condition. 
This  complication  occurs  more  frequently  after  abdominal 
operations  than  after  operations  elsewhere.  It  is  not  contagious. 
The  regular  course  is  from  seven  to  ten  days.  The  parotid  of 
the  other  side  may  become  inflamed  as  the  one  first  affected  is 
subsiding,  or  both  may  be  affected  simultaneously. 

Treatment. — The  overlying  skin  should  be  kept  scrupulously 
clean.  Pain  is  relieved  by  morphin.  An  ice-bag  is  used  to 
allay  the  inflammation.  The  mouth  should  be  frequently 
cleansed.  Should  suppuration  ensue  incision  and  free  drainage 
are  indicated.  The  incisions  are  placed  parallel  to  the  branches 
of  the  facial  nerve  to  minimize  danger  of  injury  to  this  nerve. 

Pain  is,  as  a  rule,  not  much  complained  of.  Neurotic  patients 
may  suffer  excruciating  agony  following  removal  of  a  cystic 
ovary.  Other  patients  will  suffer  but  slightly  after  much  more 
extensive  operations.  Morphin,  on  account  of  its  effect  in 
locking  up  secretions,  should  not  be  given  if  its  use  can  be 
avoided.  One  dose  for  primary  wound  pain  is  permissible.  In 
neurotic  individuals  after  the  period  of  primary  wound  pain  has 
passed,  hypodermic  injections  of  sterile  water  serve  admirably. 
Morphin  or  cocain  habitues  usually  require  small  doses  of  the  drug 


198  OPERATING    ROOM    AND    THE    PATIENT 

to  ^vhicll  they  have  been  accustomed.  Primary  wound  pain  usu- 
ally subsides  in  twenty-four  hours.  If  the  patient  is  restless  pain 
may  result  from  pulling  upon  the  stitches.  Recurrence  of  pain 
in  the  wound  after  several  days'  quiescence  is  to  be  regarded  as 
one  of  the  symptoms  of  infection.  Pain  from  distention  is 
treated  by  repeated  enemata.  In  diffuse  abdominal  pain  the 
ice  coil  proves  beneficial.  Pain  persisting  after  the  patient  is  up 
and  about  must  be  closely  inquired  into.  Not  infrequent!}'  a 
complete  change  of  scene,  tonics,  and  an  out-of-door  life  wiU 
cause  these  A-ague,  indefinite  pains  to  disappear. 

Backache  following  operations  may  be  due  to  a  hard  flat 
operating  table.  This  is  obviated  by  having  a  sufficiently  thick 
soft  pad  on  the  table.  It  is  treated  by  massage,  change  of 
posture  and  heat. 

Thirst. — Thirst  is  present  after  every  anesthetization,  and, 
in  spite  of  the  vomiting  which  the  imbibing  of  fluids  causes, 
patients  will  beg  for  water  to  ciuench  their  thirst.  The  patient 
must  not  be  allowed  to  indulge  in  excessive  fluids  shortly  after 
anesthesia,  otherwise  dflatation  of  the  stomach  may  occur. 
Since  employing  repeated  saline  enemata  complaints  of  thirst 
have  been  iiifrequent.  If  much  blood  has  been  lost,  thirst  will 
be  a  prominent  symptom. 

Treatment. — .\fter  every  operation  necessitating  anesthesia 
the  patient  should  recei^'e  an  enema  of  from  one  pint  to  one 
quart  of  saline  solution  at  a  temperature  of  110°  F.  Aside 
from  its  other  advantages,  this  will  result  in  a  great  diminution 
in  the  thirst.  This  enema  is  given  very  slowlj^,  one-haK  hour 
being  allowed  for  its  introduction  and  following  prolonged  oper- 
ations or  operations  producing  shock,  is  repeated  at  intervals 
of  four  hours,  four  times  being  usually  sufficient.  Small  c^uanti- 
ties  of  cool  or  hot  fluids  may  be  given  as  soon  as  anesthetic 
vomiting  has  ceased  unless  the  operation  has  been  one  involving 
the  stomach.  The  frequent  rubbing  of  the  mouth,  gums,  and 
lips  with  cool  water  will  prove  grateful.  A  camel's  hair  brush  is 
useful  for  moistening  the  lips  and  a  medicine  dropper  for  instilling 
cool  water  along  the  gums.  Ice  should  be  prohibited,  as  it 
tends  to  increase  thirst. 

Feeding. — For  the  first  few  hours  feeding  by  mouth  is  pro- 


GENERAL    CONSIDERATIONS    IN    THE    AFTER-TREATMENT     199 

hibited  on  account  of  the  irritability  of  the  stomach  from  the 
anesthetic.  As  soon  as  anesthetic  nausea  has  ceased,  Hquid 
food  may  be  given.  Water,  milk,  if  agreeable  to  the  patient, 
or  light  broths  are  best  for  the  first  twenty-four  hours,  the  doses 
being  small  and  so  graded  as  to  gradually  accustom  the  stomach 
to  retain  larger  amounts  at  more  extended  intervals.  At  the 
end  of  twenty-four  or  at  the  latest  forty-eight  hours  full  fluid 
diet  is  reached.  Following  this,  stronger  soups  and  farinaceous 
foods  are  given  for  a  few  days,  and  finally  meat  and  vegetables. 
Patients  lying  in  bed  do  not  require  as  large  a  quantity  of  food 
as  those  walking  about.  Overloading  the  stomach  is  to  be 
avoided.  The  character  of  the  food  should  be  such  as  to 
be  readily  assimilable.  Flatus-producing  foods  are  avoided. 
Emaciated  patients  receive  additional  nourishment  by  rectum. 
Care  must  be  exercised  in  the  selection  of  a  diet  and  individual 
taste  and  idiosyncrasy  consulted  as  much  as  possible.  The 
appetite  does  not  return,  as  a  rule,  for  one  or  two  days.  It  is 
not  necessary  to  force  the  feeding.  The  patient's  inclinations 
are  the  best  guide  as  to  the  amount  of  nourishment  that  is 
needed  in  the  first  few  days.  The  diet  should  be  a  varied  one 
as  soon  as  the  patient  is  able  to  digest  properly.  In  much 
debilitated  patients  brandy  and  water  in  the  proportion  of  one 
part  brandy  to  seven  of  water  may  be  dropped  on  the  tongue 
with  a  medicine  dropper,  or  the  lips  and  tongue  may  be 
gently  brushed  with  a  camel's  hair  brush  saturated  with  this 
solution.  While  water  is  not  absorbed  by  the  stomach  weak 
alcoholic  solutions  (5  to  15  per  cent.)  are  readily  absorbed, 
such  a  solution  being  retained  and  absorbed  when  everything 
else  is  rejected. 

Continued  loss  of  appetite  may  be  caused  by  an  unfavorable 
condition  of  the  wound.  When  by  reason  of  the  nature  of  the 
operation  swallowing  is  impossible,  or  apt  to  interfere  with  wound 
healing,  or  if  an  obstreperous  patient  refuses  nourishment, 
gavage  is  indicated. 

The  stomach  tube  is  employed  for  purposes  of  artificial  feed- 
ing (gavage).  The  instrument  is  best  made  of  thick-walled 
rubber  tubing,  with  a  smooth-edged  extremity,  or  a  lateral 
velvet-edged  opening  near  the  end. 


200  OPERATING    ROOM    AXD    THE    PATIENT 

Before  introducing  the  stomach  tube  the  distance  from  the 
lips  to  the  hypochonch'ium  should  be  measured,  in  order  to  avoid 
introducing  the  tube  too  far.  In  the  normal  esophagus  the  tube 
is  arrested  at  a  point  directly  behind  the  cricoid  cartilage,  at 
which  point  the  latter  approaches  the  vertebral  column.  In 
order  to  overcome  this  resistance  the  larynx  is  drawn  forward 
by  placing  the  tip  of  the  index-finger  of  the  left  hand  in  the 
depression  between  the  epiglottis  and  the  tongue,  and  drawing 
the  parts  forward  through  the  medium  of  the  giosso-epigiottic 
ligament.  Simply  bending  the  finger  sharply  against  the  base 
of  the  tongue  usually  suffices,  the  point  of  the  tube  being  at  the . 
same  time  directed  toward  the  posterior  pharyngeal  wall  and 
passed  downward.  The  patient  is  then  directed  to  make  efforts 
at  swallowing.  The  tube  passes  without  further  resistance  into 
the  esophagus.  For  purposes  of  artificial  feeding,  the  tube  is 
connected  to  a  glass  funnel.  The  fluid  must  be  introduced 
slowly,  otherwise  efforts  at  vomiting  will  be  provoked.  In 
cases  of  injury  of  the  pharynx  and  esophagus,  and  after  certain 
operations  about  the  neck  (extirpation  of  the  larynx,  etc.), 
the  frec[uent  introduction  of  the  stomach  tube  may  do  harm. 
Retention  of  the  tube  in  situ  by  means  of  a  safety-pin  passed 
through  its  wall,  to  which  a  tape  is  secured  and  passed  around 
the  neck  and  tied  over  the  dressings,  is  here  indicated. 

The  stomach  tube  is  also  used  for  washing  out  the  stomach 
(lavage),  the  fluid  which  has  been  introduced  being  withdrawn 
by  simply  lowering  the  glass  funnel  to  which  it  is  connected 
just  before  it  is  empty.  The  tubing  which  connects  the  funnel 
to  the  stomach  tube  being  longer  than  the  portion  which  occu- 
pies the  esophagus,  a  siphon  effect  is  produced  and  the  stomach 
is  promptly  emptied.  It  may  be  refilled  and  emptied  in  this 
manner  as  often  as  rec^uired.  Finally,  the  stomach  should  be 
siphoned  dry. 

Nasal  Feeding. — ^^Vhen  the  patient  resists,  as  the  insane,  a 
proper-sized  tube  may  be  passed  through  the  nasal  cavity  and 
thence  to  the  stomach.  This  form  of  feeding  finds  its  chief 
indication  in  children  and  in  operations  about  the  mouth  in 
which  mastication  and  swallowing  would  interfere  with  wound 
healing. 


GENERAL    CONSIDERATIONS    IN    THE    AFTER-TREATMENT     201 

Rectal  Feeding. — Rectal  feeding  is  indicated  in  debilitated 
patients  to  more  rapidly  increase  nutrition;  in  irritative  condi- 
tions of  the  stomach  such  as  persistent  vomiting;  in  obstructed 
lesions  of  the  pharynx  and  esophagus;  in  lesions  of  the  stomach 
in  which  stomach  rest  is  desirable;  in  general  conditions  of  the 
patient  such  as  shock,  coma  and  delirium;  in  cases  such  as  diffuse 
septic  peritonitis  in  which  peristalsis  is  to  be  avoided;  as  an 
adjunct  to  gavage  in  the  after-treatment  of  operations  on  the 
mouth  and  its  neighborhood.  The  enema  is  administered  in  the 
same  manner  as  an  ordinary  enema  but  more  slowly,  allowing 
fifteen  to  twenty-five  minutes  for  the  administration.  The 
quantity  administered  will  depend  upon  the  patient's  ability  to 
retain  it,  from  four  to  ten  ounces  every  four  to  six  hours.  After 
the  enema  has  been  administered,  pressure  with  a  folded  towel 
should  be  made  firmly  against  the  anus  to  cause  the  retention 
of  the  enema.  This  pressure  should  be  maintained  as  long  as 
the  desire  to  expel  the  enema  persists.  If  the  fluid  is  admin- 
istered slowly  through  a  small  catheter  at  a  temperature  of  blood 
heat,  in  a  proper  quantity  for  the  individual  and  firm  pressure 
is  made  following  its  introduction  it  will  usually  be  retained. 
The  rectum  should  be  cleansed  once  daily  by  saline  irrigation. 
Great  care  and  gentleness  are  essential,  as  otherwise  an  irritative 
condition  of  the  rectum  will  be  set  up  which  will  result  in  the 
rejection  of  the  enema.  Where  rectal  feeding  alone  is  relied 
upon  it  will  be  necessary  to  give  saline  for  retention  twice  daily 
in  addition  to  the  nutrient  enema  in  order  to  maintain  the  body 
fluids.  In  cases  in  which  the  Murphy  method  of  proctoclysis 
is  used  the  nutrient  material  may  be  placed  in  the  receptacle  for 
the  proctoclysis.  The  formula  recommended  by  Ewald  of  two 
tablespoonfuls  of  wheat  flour  stirred  up  with  150  c.c.  of  warm 
milk  or  water  to  which  is  slowly  added  while  still  stirring  one  or 
two  eggs  and  a  pinch  of  salt,  and  the  whole  beaten  up  with 
50  c.c.  of  a  15  per  cent,  solution  of  grape  sugar,  is  highly  satis- 
factory. The  addition  of  a  half  ounce  to  an  ounce  of  claret 
promotes  absorption  and  favors  retention.  Other  formulas  are 
those  of  Leube,  milk  three  ounces,  peptone  two  ounces;  Boas, 
milk  eight  ounces,  yolk  of  two  eggs,  a  pinch  of  salt  and  red  wine 
one-half  ounce,  starch  or  flour  one  table  poonful.     These  three 


202  OPEKATIXG    EOOM    AXD    THE    PATIENT 

formulas   represent    the  foundation   of   most   nutrient   enemas. 
In  prolonged  rectal  feeding  they  should  be  alternated. 

Sterile  Feeding. — In  cases  in  -^hich  it  is  desirable  to  reduce  the 
number  of  bacteria  in  the  gastrointestinal  tract  to  a  minimum, 
sterile  feeding  is  indicated.  It  has  been  demonstrated^  that  it 
is  possible  to  render  the  stomach  and  intestines  sterile  as  a  pre- 
paratory measure  before  operations.  The  teeth  are  brushed 
and  the  mouth  rinsed  with  an  antiseptic  solution  before  and 
after  every  feeding  as  well  as  several  times  daily.  If  a  test 
meal  shows  the  presence  of  microorganisms  in  the  stomach,  the 
stomach  is  washed  out  twice  daily.  A  diet  consisting  of  boiled 
water,  sterilized  milk,  beef  tea,  albumen  water,  and  similar 
fluids  is  administered  in  small  amounts  at  frequent  intervals 
from  sterile  vessels.  For  six  to  ten  hours  previous  to  operation 
nothing  is  given  by  mouth,  rectal  feeding  being  substituted. 

Subcutajieous  Feeding. — This  is  rarely  indicated.  In  all 
probability  most  of  the  cases  in  which  it  has  been  used  have 
been  more  benefited  by  the  fluid  introduced  in  this  manner 
than  by  the  actual  food  value  of  the  material.  Five  and  10 
per  cent,  solutions  of  grape  sugar,  olive  oil,  and  dilute  milk 
and  peptone  solutions  have  been  used.  Grape-sugar  solutions 
are  apt  to  set  up  an  irritation  at  the  site  of  injection.  An  injec- 
tion of  olive  oil  is  not  without  the  theoretic  danger  of  fat  embo- 
lism. The  fluid  injected  should  be  sterilized  and  all  aseptic 
precautions  should  be  used.  A  quantity  of  not  more  than  30  c.c, 
should  be  injected  in  any  one  place. 

Gastrostomy  Feeding  (p.  456). 

Jejunal  Feeding  (p.  460). 

The  digestion  of  the  food  should  be  ascertained.  Constipa- 
tion and  flatulence  are  watched  for  and  remedied  as  far  as  pos- 
sible by  diet.  Apple  sauce,  prunes,  grapes,  orange  and  lemon 
juice,  and  Vichy  water  wiU  be  found  of  value  in  this  regard. 
Lack  of  accustomed  exercise  vri]l  account  for  constipation  in 
most  cases.  Enemata,  either  of  soapsuds  and  warm  water  or 
containing  spirit  of  turpentine,  ox-gall,  lac  asafetida,  or  alum, 
according  to  the  severity  of  the  case,  are  indicated  if  a  natural 
movement  does  not  result  in  forty-eight  hours. 

^  Har^-ey  Gushing,  John  Hopkins  Hospital  Reports,  voL  ix. 


GENERAL    CONSIDERATIONS    IN    THE    AFTER-TREATMENT     203 

Distention  is  relieved  by  enemata,  by  the  passage  of  the 
rectal  tube,  and  by  the  elevated  head  and  trunk  position.  In 
elderly  persons  suffering  from  atony  of  the  intestinal  wall, 
treatment  of  flatulence  must  be  vigorous  and  initiated  early. 
Tincture  of  belladonna  is  useful  in  this  condition.  Calomel 
and  salines  may  be  necessary  to  produce  thorough  evacuation. 
A  single  dose  of  castor  oil  will  often  prove  beneficial.  During 
convalescence,  massage,  both  general  and  local,  is  of  value.  A 
natural  cathartic  water,  or  one  teaspoonf  ul  of  the  fluid  extract  of 
cascara  (aromatic)  combined  with  the  fluid  extract  of  licorice 
is  given  at  bedtime.  The  bowels  should  move  once  daily  while 
the  patient  is  in  bed,  with  the  exception  of  the  first  day.  If 
regular  movements  do  not  occur,  intestinal  toxemia  is  apt  to 
develop.  This  is  shown  by  a  furred  condition  of  the  tongue, 
foul  breath,  distention,  abdominal  discomfort,  and  a  rise  of 
temperature.  Following  a  free  bowel  movement  the  unpleasant 
symptoms  subside.  In  the  care  of  the  bowels  in  operations 
involving  the  integrity  of  the  intestinal  wall  reliance  is  placed 
upon  enemata.  No  cathartic  is  given  until  the  tenth  day.  Fe- 
cal impaction  may  result  if  proper  attention  is  not  paid  to  the 
movements.  It  occurs  particularly  in  old  people.  Occurring 
in  the  rectum,  the  patients  will  complain  of  rectal  distress. 
There  will  be  small  fluid  evacuation  without  relief.  Rectal 
examination  reveals  a  large  mass  of  hardened  feces.  This  will 
necessitate  spooning  the  hardened  fecal  masses  from  the  rectum 
and  the  administration  of  a  course  of  calomel  and  castor  oil  and 
olive  oil  enemata. 

Enemata  and  Colonic  Irrigations. — ^In  surgery,  these  take  the 
place  of  cathartics  for  the  most  part  and  are  sufficient.  A  short 
rectal  tube  is  as  useful  as  a  long  one.  If  the  enema  or  irrigation 
is  given  slowly  retroperistalsis  takes  the  fluid  up  into  the  colon 
and  normal  peristalsis  then  returns  it  when  the  colon  is  distended. 

Enemata. — ^Technic  of  enemata  for  the  purpose  of  evacua- 
tion. High  enemata.  The  temperature  of  the  solution  should 
be  100°  F.,  the  tube  is  coated  with  vaselin  and  a  small  amount 
of  fluid  allowed  to  run  through  the  tube  in  order  that  no  air  will 
be  injected.  With  the  patient  in  the  recumbent  position  on  a 
bed-pan,  and  the  knees  drawn  up,  the  buttocks  are  separated 


204  OPERATING    ROOM    AND    THE    PATIENT 

with  the  left  hand  and  "U'hile  the  patient  strains  sHghtly  to  relax 
the  sphincter  the  tip  of  the  tube  is  pressed  against  the  anus  and 
inserted  in  an  upward  and  slightly  forward  direction.  As  soon  as 
the  tube  has  passed  the  sphincter  the  direction  is  changed  some- 
what backward.  If  resistance  is  met  with  the  tube  is  slightly 
withdrawn  and  again  advanced;  while  this  is  being  done  the 
further  passage  of  the  tube  is  facilitated  by  allowing  the  fluid  to 
slowly  flow.  In  the  majority  of  cases  it  is  not  possible  to  intro- 
duce the  tube  more  than  six  or  seven  inches  without  its  coiling 
on  itself.  When  the  tube  has  been  introduced  as  far  as  is  prac- 
ticable with  gentleness  the  flow  is  continued  until  the  desired 
amount  is  introduced.  For  purposes  of  evacuation  a  sufficient 
amount  must  be  introduced  to  distend  the  intestine,  from  one 
pint  to  one  quart  or  more.  During  the  course  of  the  flow  the 
patient  may  complain  of  fullness  in  the  rectum  and  inability 
to  hold  the  fluid;  if  the  flow  is  temporarily  stopped,  the  rectum 
will  become  used  to  the  pressure  and  more  fluid  may  then  be 
injected.  When  no  more  can  be  introduced  with  comfort  the 
flow  is  stopped  and  the  tube  withdrawn.  The  patient  should  be 
instructed  to  retain  the  enema  for  ten  minutes  if  possible. 

Low  Enemata. — ^In  administering  a  low  enema  an  ordinary 
small  hard  rubber  rectal  pipe  is  gently  inserted  until  its  tip  is 
well  within  the  external  sphincter;  the  solution  is  then  allowed 
to  run  in  slowly.  Low  enemata  are  desirable  in  fecal  fistulas 
of  the  large  intestine  in  which  a  high  enema  may  result  in  wash- 
ing the  fecal  matter  through  the  wound  instead  of  causing  pro- 
pulsion in  the  normal. direction. 

Enemas  are  given  in  preference  to  cathartics  following  any 
operation  upon  the  bowel,  and,  generally  speaking,  after  abdom- 
inal operations,  enemas  are  far  preferable  to  catharsis.  If  the 
operation  on  the  bowel  has  been  low  down,  enemas  are  contrain- 
dicated.  For  the  purpose  of  producing  evacuation,  enemas  vary 
in  composition.  The  ordinary  "  SS  "  enema  consists  of  two  quarts 
of  strong  solution  of  soapsuds;  castile  soap  is  preferable.  If  this  is 
not  effectual  a  more  stimulating  enema  must  be  used.  Such  an 
enema  is  composed  of  glycerin,  1  1/2  oz.,  magnesium  sulphate,  1 
oz.,  water,  2  1/2  oz.;  or,  turpentine,  1/2  oz.,  hot  water  and  soap, 
1/2  pt.,  castor  oil,  1  oz.;  or,   ox-gall,  2  drams,  glycerin,  4  oz., 


GENERAL    CONSIDERATIONS    IN    THE    AFTER-TREATMENT     205 

warm  water,  1  pt.  Various  combinations  of  glycerin,  olive  oil, 
ox-gall,  magnesium  sulphate  and  turpentine  with  warm  water 
are  used.  A  very  efficient  enema  consists  of  one  quart  of  hot 
water  in  which  is  dissolved  one  ounce  of  alum.  Another  almost 
equally  efficient  enema  consists  of  one  pint  of  milk  and  molasses. 
An  alternation  of  these  latter  enemas  is  useful  at  times.  Milk 
of  asafetida,  3  oz.,  either  alone  or  in  solution  is  useful.  If  much 
irritation  is  produced  from  stimulating  enemas  an  enema  of  one 
ounce  of  starch  with  sufficient  cold  water  to  make  a  paste  and 
the  addition  of  boiling  water  to  dilute  this  mixture  to  the  con- 
sistency of  mucilage,  or  the  injection  of  a  few  ounces  of  olive 
oil  occasionally  into  the  rectum  will  prove  soothing. 

Colonic  Irrigation. — Colon  irrigations  are  indicated  for  the 
purpose  of  completely  emptying  the  colon  before  operations 
upon  the  rectum  and  colon,  for  the  treatment  of  diseases  of  the 
colon  and  for  the  purpose  of  causing  rapid  absorption  of  a 
large  quantity  of  saline.  The  latter  indication  is  now  fulfilled 
surgically  by  proctoclysis  by  the  Murphy  method.  A  Kemp's 
(Fig.  146)  or  Tuttle's  tube  may  be  employed,  or  in  an  emergency 


I   g.   146. — Kemp's  tube  for  colonic  irrigation. 

an  ordinary  rectal  tube  with  a  T-attachment  may  take  their 
place.  The  simplest  apparatus  consists  of  a  receptacle  (a 
douche  bag  or  can)  for  holding  the  saline  or  whatever  medicated 
solution  is  indicated,  a  length  of  rubber  tubing,  a  T-shaped  con- 
nection, a  rectal  tube  and  a  length  of  rubber  tubing  with  a  clip  for 
the  outflow.  Rubber  sheeting  prevents  soiling;  a  large  pail  is 
used  to  collect  the  irrigating  fluid.  Several  pitchers  of  irrigat- 
ing fluid  at  the  proper  temperature  should  be  at  hand.  The 
patient  is  placed  preferably  in  the  Sim's  position  with  the  hips 
elevated.     Changing  the   position   of   the   patient   occasionally 


206  OPERATING    ROOM    AND    THE    PATIENT 

allows  the  solution  to  reach  all  parts  of  the  colon.  The  fluid 
at  a  temperature  of  100°  F.  to  105°  F.  is  allowed  to  flow  sloidy 
to  avoid  exciting  peristalsis.  Elevation  of  the  receptacle  from 
two  to  four  feet  gives  the  proper  flow.  If  the  simplest  apparatus 
is  used  the  fluid  is  introduced  with  the  clip  on  the  outlet  tube 
closed  until  the  colon  is  well  distended,  the  average  individual 
being  able  to  hold  one  to  two  quarts  without  much  discomfort. 
The  inflow  tube  is  then  pinched,  the  clip  on  the  outlet  tube  opened, 
allowing  the  fluid  to  return  through  the  rectal  tube  and  outflow 
tube  into  the  pail.  In  pre-operative  preparations  the  irrigation 
is  continued  until  the  fluid  returns  clear.  It  is  usually  necessary 
to  use  several  gallons.  A  much  more  efficient  irrigation  is 
obtained  by  using  either  a  Kemp's  or  Tuttle's  tube. 

Proctoclysis. — ^The  employment  of  proctoclysis  in  the  treat- 
ment of  peritonitis  and  general  toxic  conditions  is  of  the  utmost 
value.  By  its  use  the  tissues  are  flushed  by  the  absorption  of 
large  quantities  of  saline  solution,  all  elimination  is  made  more 
active  and  toxins  are  rapidly  eliminated.  In  1899  and  for  some 
years  previous  to  that  time,  it  was  our  practice  to  give  saline 
by  rectum  for  the  pui'pose  of  absorption  after  every  laparotomy 
both  for  the  relief  of  the  thirst  and  to  prevent  deleterious  effects  of 
the  anesthetic  upon  the  kidneys.  A  pint  to  a  quart  of  saline  at  a 
temperature  of  110°  F.  is  given  through  a  small  catheter,  allowing 
twenty  to  thirty  minutes  for  its  administration.  This  is  repeated 
at  four-hour  intervals  so  long  as  toxic  or  shock  symptoms  prevail. 

Murphy  Method} — ^The  apparatus  for  Murphy  proctoclysis 
consists  of  a  fountain  syringe  or  douche  can  with  a  large  rubber 
tube  attached,  connected  with  a  vaginal  hard  rubber  or  glass 
tip,  flexed  at  an  obtuse  angle  two  inches  from  its  tip  and  having 
numerous  openings  at  its  bulbed  end  (Fig.  147).  The  tip  is 
inserted  into  the  rectum  so  that  the  angle  fits  closely  to  the 
sphincter  and  the  tube  is  then  secured  to  the  thigh  by  adhesive- 
plaster  strips  to  prevent  expulsion.  The  receptacle  for  saline 
is  suspended  so  that  its  base  is  from  six  to  eight  inches  above 
the  level  of  the  buttocks.  The  connecting  tube  should  be  as 
short  as  possible  and  yet  allow  of  not  being  dragged  upon  by 
slight   movements   of  the   patient.     Once   having  secured   the 

^Journal  American  Medical  Association,  April  17,  1909. 


GENERAL    CONSIDERATIONS    IN    THE    AFTER-TREATMENT     207 

proper  level  for  the  receptacle  it  need  not,  except  to  increase  or 
decrease  the  speed  of  the  influx,  be  disturbed  until  the  procto- 
clysis is  no  longer  indicated.  Saline  solution  at  a  temperature 
of  100°  F.  is  placed  in  the  receptacle.  This  temperature  is  main- 
tained by  placing  hot  water  bags  around  the  receptacle  and 
covering  the  whole  with  flannel.     Various  means  for  keeping 


Fig.   147. — Apparatus  for  Murphy  proctoclysis. 

the  solution  at  the  proper  temperature  have  been  devised,  but 
the  above  is  the  simplest  for  general  use.  Murphy  gives  an 
average  of  eighteen  pints  in  twenty-four  hours  and  believes 
that  less  than  eight  pints  is  of  little  value.  The  retention  of  the 
fluid  depends  upon  the  slowness  of  its  flow.  If  too  rapid  a  flow 
is  allowed  the  large  intestine  becomes  overdistended  causing  a 
spasm  and  consequent  expulsion  of  the  fluid.     The  flow  may  be 


208 


OPERATIXG    ROOM    AXD    THE    PATIENT 


continued  for  days  T\'ith  little  disturbance.  If  too  much  fluid 
is  being  absorbed  it  will  be  shov\-n  by  slight  edema  of  the  ankles, 
hands  and  sometimes  of  the  face,  thereupon  the  proctoclysis 
should  be  discontinued  until  the  circulatory  equilibrium  is  re- 
stored; usually  proctoclysis  employed  for  three  days  is  sufficient, 
more  rarely  as  long  as  five  or  six.  Every  two  hours  one  and  a 
half  pints  of  solution  are  placed  in  the  receptacle.  At  the  normal 
rate  of  flow  the  receptacle  will  become  empty  in  40  to  60  minutes, 
thus  allowing  the  rectum  a  period  of  rest  of  about  an  hour. 

In  cases  in  which  the  heart  muscle  is  weak  care  should  be 
taken  not  to  OA^erburden  the  tissues  with 
fluid.  This  is  jDarticularly  true  in  the  later 
stages  of  pneumonia.  The  control  of  the 
jflow  should  never  be  interfered  with  by 
lessening  the  lumen  of  the  inflow  tube  or  by 
haA'ing  few  openings  in  the  tip.  If  a 
Y-shaped  connecting  tube  is  used  with  a 
second  tube  leading  back  to  the  can  this 
restriction  is  not  essential,  as  the  return 
tube  ensures  accurate  regulation  of  the 
quantity  of  fluid  administered,  regularity  of 
flow,  and  prevents  overdistention  of  the 
bowel.  By  using  a  Y-shap:d  tube  the  result 
is  practically  a  slow  Kemp's  irrigation  of  the 
large  intestine  with  the  absorption  of  all  of 
the  fluid.  In  case  a  Y-shaped  tube  is  not 
used  it  is  essential  that  a  large  inflow  tube 
be  used  and  that  the  rectal  tip  have  numer- 
ous openings  to  provide  for  the  sudden 
return  of  the  flow  into  the  can  when  the 
patient  strains,  wishes  to  expel  fluid  or  void 
gas.  Any  attempt  to  constrict  the  tube  and  thus  control  the  flow 
will  result  in  the  expulsion  of  the  fluid  alongside  the  tube  and  the 
consecpent  soiling  of  the  bed.  The  lowest  level  and  the  shortest 
inflow  tube  give  the  best  results.  A  saline  drop  regulator  of 
which  several  have  been  devised  and  of  which  that  devised  by 
E.  C.  RyalP  (Fig.  148)  is  a  type,  is  useful  though  not  essential. 


Fig.  148. — Drop 
regulator  for  use  in 
proctoclysis. 


1  Lancet,  Xov.  18,  1911. 


GENERAL    CONSIDERATIONS    IN    THE    AFTER-TREATMENT     209 

The  barrel  is  made  of  toughened  annealed  glass  and  nickel- 
plated  metal  mounts  at  either  end  for  attaching  the  tube 
securely  cemented  with  metallic  solder  so  that  the  appartus 
can  be  sterilized.  The  stopcock  allows  of  the  regulation 
of  the  number  of  drops;  three  drops  per  second,  is  the  rate 
advised  by  Murphy.  Instruments  of  this  kind  also  allow 
of  a  short  length  of  tubing  between  the  saline  receptacle 
and  the  rectum  as  the  rate  of  flow  can  be  controlled  by  the 
apparatus  and  the  receptacle  need  not  be  raised  or  lowered.  It 
is  necessary  that  the  nurse  note  the  rate  of  flow  frequently. 
When  such  an  apparatus  is  used,  however,  it  is  best  to  use  it  in 
conjunction  with  the  Y-shaped  return  tube  already  mentioned. 

Singultus  is  a  spasmodic  contraction  of  the  diaphragm  causing 
inspiration,  followed  by  a  sudden  closure  of  the  glottis.  In 
ordinary  circumstances  this  is  a  comparatively  harmless  affair 
to  which  any  one  is  subject;  occurring  post-operatively,  how- 
ever, in  patients  weakened  by  disease  and  operation  it  may  prove 
disastrous.  It  is  caused  by  the  irritation  of  the  terminal  fila- 
ments of  the  pneumogastric  nerve  or  by  irritation  of  the  phrenic 
nerve.  Inflammations  and  tumors  in  the  course  of  these  nerves 
or  irritative  substances  so  located  as  to  irritate  the  terminal 
filaments,  are  apt  to  be  complicated  by  hiccough.  One  of  the 
most  frequent  causes  is  irritative  substances  in  the  stomach 
itself  or  lower  down  in  the  digestive  tract.  Occasionally  the 
trouble  seems  to  be  purely  neurotic,  being  discontinued  during 
sleep.  In  other  cases  it  is  almost  continuous.  Once  started,  the 
arhythmia  is  apt  to  continue.  The  hiccough  will  occur  at  short 
or  long  intervals.  Post-operatively  it  occurs  in  renal  complica- 
tions, in  peritoneal  inflammations,  in  intestinal  obstruction, 
in  tumors  and  inflammations  in  relation  wih  the  diaphragm, 
and  more  rarely  in  inflammations  so  located  as  to  irritate  the 
pneumogastric  filaments  of  the  upper  air  passages. 

Treatment. — ^In  cases  without  ascertainable  cause,  diverting 
the  attention  as  by  the  common  method  of  holding  the  breath 
and  making  pressure  upon  the  upper  lip  will  cause  its  disappear- 
ance. Mild  cases  respond  to  this  method  or  to  the  administra- 
tion of  carminatives,  such  as  aromatic  spirits  of  ammonia,  com- 
pound spirits  of  ether,  compound  tincture  of  cardamon,  etc. 

14 


210  OPERATIXG  ROOM  AND  THE  PATIEXT 

Immediately  upon  the  occurrence  of  hiccough  a  thorough 
examination  of  the  patient  should  be  made,  the  cause  ascertained 
if  possible  and  treatment  for  the  cause  instituted.  Treatment 
for  the  hiccough  itself  consists  in  lavage  of  the  stomach  and 
siphoning  dry;  in  the  removal  by  enemata,  or  mild  purgation  if 
the  operation  allo"v\'s,  of  possible  irritations  in  the  intestinal  canal; 
in  the  elevation  of  the  head  of  the  bed  to  obviate  pressure  upon 
the  diaphragm,  in  intraabdominal  conditions;  in  counter-irritation 
applied  to  the  epigastrium  in  the  form  of  mustard,  turpentine, 
ice  or  the  actual  cautery,  in  cases  in  which  the  incision  permits; 
the  administration  of  atropin  and  morphin  by  hypodermic, 
either  alone  or  in  combination,  Atropin  in  large  doses  seems  to 
be  the  most  effectual  single  remedy.  The  administration  of  hot 
and  cold  liquids,  the  rapid  sipping  of  fluids  or  a  quantity  of 
thick  farinaceous  material;  lumps  of  ice,  ice  cream,  rhji;hmic 
traction  of  the  tongue,  forcible  traction  of  the  tongue,  cocainiza- 
tion  of  the  pharjmx,  pressure  on  the  pneumogastric  nerve  in  the 
neck,  pressure  on  the  supraorbital  nerve,  pressure  on  the  lower 
costal  arches,  with  the  idea  of  relaxing  the  diaphragm;  tight 
bandaging  of  the  lower  portion  of  the  chest  with  the  same  idea 
in  view;  sudden  mental  shock;  chloral,  amyl  nitrite,  faridization 
of  the  phrenic  nerve;  all  these  may  be  tried. 

In  cases  where  all  efforts  to  stop  the  hiccough  have  failed 
and  the  patient  is  becoming  exhausted  from  lack  of  sleep,  anes- 
thesia by  ether  or  chloroform  is  indicated. 

Supportive  treatment  must  not  be  neglected.  Food,  stimula- 
tion, and  fluids  must  be  administered,  if  not  by  stomach,  then  by 
rectum  and  endermically. 

Dilatation  of  the  Stomach  and  Duodenum. — ^This  post-operative 
complication  is  rare,  though  of  late  Cjuite  a  few  cases  have  been 
reported.  Many  of  the  cases  reported  have  been  attributed  to 
nervous  causes.     Such  has  not  been  our  experience. 

The  lesion  is  at  first  a  mechanic  one,  later  the  stomach  and 
duodenum  undergo  a  paresis  due  to  their  continued  and  great 
distention.  P,  Miller^  describes  a  condition  which  he  designates 
as  mesenteric  incarceration  of  the  duodenum,  A  case  of  this 
character  came  under  our  observation  and  died  in  spite  of  early 

^  Deutsche  Zeitschrift  Jiir  Chirurgie,  vol.  h"i,  p.  486. 


GENERAL    CONSIDERATIONS    IN    THE    AFTER-TREATMENT     211 

diagnosis,  repeated  washing  out  of  the  stomach,  and  change  of 
position.  The  autopsy  verified  the  diagnosis.  On  opening  the 
abdomen  an  enormously  dilated  stomach  reaching  fiom  the 
free  border  of  the  ribs  to  the  symphysis  was  seen.  The  dilated 
stomach,  stretched  almost  beyond  recognition,  filled  the  entire 
abdominal  cavity.  On  raising  the  stomach  up  there  was  dis- 
closed collapsed  small  intestine  filling  the  pelvis.  The  duodenum 
was  enormously  dilated  and  from  the  duodeno-jejunal  juncture 
collapsed  jejunum  descended  into  the  pelvis.  At  the  duodeno- 
jejunal juncture  the  mesentery  of  the  small  intestine  was  so 
drawn  upon  as  to  constrict  the  gut  at  this  point. 

This  condition  seems  to  be  brought  about  by  the  tension  of 
the  mesentery  of  the  small  intestine,  this  tension  being  produced 
by  the  sinking  of  the  small  intestine  into  the  pelvis  thus  causing 
the  duodenum  to  press  against  the  superior  mesenteric  artery 
and  vein,  and  so  completing  the  obstruction.  The  condition 
is  favored  by  too  rapid  ingestion  of  fluids  in  a  stomach  weakened 
by  anesthesia.     This  is  an  avoidable  cause. 

In  most  of  the  reported  cases  the  condition  has  followed 
laparotomy,  but  it  may  occur  after  operations  upon  other  por- 
tions of  the  body.  The  symptoms  are  characteristic.  There  is 
first  distention  of  the  stomach  and  duodenum.  This  may  begin 
directly  after  anesthetization,  or  may  be  delayed  for  three  or 
four  days  or  even  later.  The  stomach  and  duodenum  gradually 
fill  up.  This  distention  is  marked  by  a  tumor  above  the  umbili- 
cus, the  remainder  of  the  abdomen  not  being  distended.  Vomit- 
ing is  persistent  and  profuse,  though  the  stomach  is  rarely  com- 
pletely emptied.  The  vomited  matter  consists,  first,  of  what- 
ever fluid  has  been  introduced  into  the  stomach;  second,  of 
stomach  secretion  mixed  with  bile;  and  third,  of  duodenal  con- 
tents. It  never  becomes  fecal.  There  is  no  pain,  but  a  great 
deal  of  distress.  The  distention  of  the  stomach  gradually 
increases  until  the  stomach  may  occupy  the  entire  abdomen. 
At  first  there  is  little  gas  or  fecal  matter  passed.  There  is  no 
rise  in  temperature.  The  pulse  becomes  rapid,  prostration  is 
marked.  The  patient's  countenance  expresses  anxiety,  there  is 
extreme  thirst.  Intestinal  obstruction  from  other  causes  is 
ruled  out  by  the  absence  of  fecal  vomiting,  the  enormous  quan- 


212  OPERATING    ROOM    AND    THE    PATIENT 

tity  of  the  vomited  material  and  its  character.  Occurring  after 
abdominal  section,  this  complication  should  be  readily  diagnosed, 
as  the  after-treatment  of  all  cases  of  abdominal  section  should 
include  frequent  palpation  of  the  abdomen  to  determine  the 
presence  of  distention.  In  cases  of  dilatation  of  the  stomach 
and  duodenum  the  distention  of  the  upper  part  of  the  abdomen 
will  thus  be  early  recognized  and  prompt  measures  may  be 
instituted  for  its  relief.  I  have  seen  three  additional  cases  in 
which  there  was  marked  dilatation  of  the  stomach  occurring 
two  and  three  days  following  operations  for  appendicitis.  The 
distention  was  only  marked  above  the  umbilicus;  below  there 
was  no  distention.  Under  repeated  lavage  and  change  of  posi- 
tion these  patients  recovered.  It  may  be  noted  that  in  none  of 
the  cases  personally  observed  had  the  elevated  head  and  trunk 
position  been  employed. 

Treatment. — ^Treatment  to  be  effectual,  must  be  instituted 
early,  before  extreme  dilatation  and  consequent  paresis  has 
occurred.  It  may  be  that  the  gradual  filling  up  of  the  stomach 
and  duodenum,  with  a  slight  kinking  at  the  duodeno-jejunal 
juncture,  is  a  sufficient  producing  cause  for  the  condition;  the 
absolute  obstruction  being  kept  up  by  the  pressure  of  the 
dilated  duodenum.  This  would  seem  to  be  true  for  the  reason 
that  cases  with  characteristic  clinical  symptoms  recover  without 
operation.  The  treatment  consists  in  repeated  lavage  and 
complete  emptjdng  of  the  stomach  and  duodenum,  in  abstinence 
from  mouth  feeding,  in  the  frequent  change  in  the  position  of  the 
patient,  rectal  alimentation  and  hypodermoclysis  and  such  sup- 
portive measures  as  the  general  condition  of  the  patient  requires. 
The  foot  of  the  bed  should  be  raised  with  the  view  of  causing  the 
collapsed  small  intestine  to  gravitate  from  the  pelvis  toward  the 
diaphragm  and  so  relieve  the  tension  upon  the  duodenum.  This 
will  be  further  facilitated  by  turning  the  patient  on  the  stomach 
and  then  raising  the  foot  of  the  bed.  The  abdominal  binder 
should  be  snugly  applied.  If  in  spite  of  change  of  posture  and 
repeated  lavage  with  siphoning  dry  of  the  stomach  the  symp- 
toms still  persist  it  will  be  necessary  to  open  the  abdomen.  If 
at  such  an  operation  the  stomach  and  duodenum  present  the 
appearance  of  paresis  a  gastrojejunostomy  with  lateral duodeno- 


GENERAL    CONSIDERATIONS    IN    THE    AFTER-TREATMENT     213 

jejunostomy  must  be  done.  If  gastrojejunostomy  alone  is 
done,  in  all  probability  the  symptoms  will  still  continue  on 
account  of  the  reversed  peristalsis  of  the  paretic  duodenum. 

The  general  rules  of  hygiene  must  be  carried  out.  The  room 
and  surroundings  are  made  as  pleasant  as  possible.  There  must 
be  plenty  of  fresh  air.  The  bedclothes  must  be  clean  and 
changed  frequently.  The  patient's  skin  must  be  kept  clean 
by  sponge  baths.  Care  is  taken  that  the  patient  is  not  chilled. 
Vaginal  douches  are  given  as  required.  The  teeth,  hair,  and 
nails  should  receive  attention.  Not  only  is  the  patient  thus 
kept  comfortable,  but  wounds  will  heal  more  quickly,  if  hygienic 
conditions  are  good.  General  massage  should  be  given  to 
increase  the  action  of  the  skin  and  keep  up  muscle  tone. 

The  urine  must  be  watched  carefully.  In  all  cases  the  total 
quantity  passed  in  the  first  twenty-four  hours  is  recorded,  A 
sample  of  the  urine  with  the  name,  date,  and  the  amount  passed, 
is  sent  to  the  pathologist  for  examination.  The  same  procedure 
is  carried  out  on  the  tenth  day.  In  cases  presenting  kidney 
complications  the  urine  is  examined  more  frequently. 

Albuminuria  may  develop  as  a  result  of  the  anesthetic.  This 
will,  as  a  rule,  disappeai  by  the  tenth  day,  and  is  not  signifi- 
cant of  a  kidney  lesion.  Should  diabetes  or  renal  disease  develop, 
the  urinalysis  will  give  the  first  clue  and  treatment  may  be  begun 
promptly. 

Cystitis  may  follow  the  use  of  the  catheter,  particularly  in 
females.  With  careful  avoidance  of  traumatism  and  cleanliness 
in  technic,  catheter  cystitis  should  rarely  occur.  Early  cathet- 
erization is  of  value  as  showing  whether  the  kidneys  are  properly 
functionating  or  not. 

Anuria  may  occur  after  any  anesthetization,  but  is  more 
likely  to  occur  after  operations  involving  the  urinary  apparatus; 
next  in  frequency  after  laparotomies.  It  may  be  caused  by  the 
absorption  of  strong  antiseptics,  such  as  carbolic  acid  and 
bichlorid  of  mercury.  Treatment  consists  in  cupping  the 
kidney  areas,  and  administration  of  saline  by  colon  or 
endermically. 

Retention  of  Urine. — The  bladder  must  not  be  allowed  to 
become  distended.     If  the  patient  has  not  urinated  voluntarily 


214  OPERATING    ROOM    AND    THE    PATIENT 

in  ten  to  twelve  hours  the  catheter  is  used.  It  is  not  necessary 
to  catheterize  until  this  time,  provided  the  bladder  has  been 
emptied  prior  to  the  operation,  as  the  amount  of  urine  secreted 
in  the  first  twelve  hours  is  not  sufficient  to  unduly  distend  the 
bladder.  A  suprapubic  examination  of  the  bladder  will  show 
whether  the  use  of  the  catheter  is  imperative.  Subsequent 
catheterization  may  be  done  every  six  or  eight  hours  as  indicated. 
It  should  be  discontinued  as  soon  as  possible. 

Applying  hot  compresses,  turning  the  patient  on  the  side,  or, 
if  feasible,  allowing  the  patient  to  get  out  of  bed  may  cause  the 
urine  to  be  passed  voluntarily. 

Catheterization  in  the  Female. — ^Many  a  patient's  life  has 
been  rendered  almost  unbearable  because  of  a  cystitis  acquired 
through  carelessness  in  catheterization.  The  hands  are  scrubbed 
and  thoroughly  disinfected.  The  parts  surrounding  the  urethral 
orifice  are  cleansed  with  sterile  water,  followed  by  swabbing 
with  a  mild  antiseptic  solution.  The  patient  lies  on  her  back 
with  the  thighs  well  separated  and  the  limbs  flexed  at  the  knees. 
The  parts  should  be  exposed  to  a  good  light.  It  is  preferable 
to  use  a  glass  catheter  on  the  score  of  cleanliness.  If  such  a  one 
is  not  at  hand,  a  silver  instrument  may  be  used.  It  is  rendered 
aseptic  by  boiling  and  is  lubricated  with  olive  oil.  The  instrument 
is  gently  inserted  within  the  urethral  orifice  and  pushed  without 
force  along  the  urethra.  As  soon  as  the  bladder  is  entered  the 
urine  will  flow  through  the  catheter  into  the  vessel  held  to  re- 
ceive it.  Following  catheterization  there  may  persist  a  slight 
degree  of  vesical  irritability.  To  avoid  this  the  bladder  is 
irrigated  after  each  catheterization  with  a  2  per  cent,  boric 
acid  solution  and  two  drams  of  5  per  cent,  argyrol  are  left  in  the 
bladder.  The  danger  of  infection  of  the  bladder,  ureters,  or 
kidneys  must  be  borne  in  mind  at  every  catheterization.  The 
resulting  cystitis  is  quite  as  apt  to  be  due  to  actual  injury  to  the 
delicate  bladder  mucosa  as  to  infection  introduced  from  without. 
For  this  reason  the  utmost  care  is  necessary  in  performing  the 
catheterization  as  gently  as  possible,  using  a  very  small  in- 
strument. When  pain  is  complained  of  it  is  usually  because  too 
large  an  instrument  has  been  used. 

Catheterization  in  the  Male.  — The  entire  procedure  is  conducted 


GENERAL    CONSIDERATIONS    IN    THE    AFTER-TREATMENT     215 

with  aseptic  precautions.  The  hands  of  the  operator,  the 
patient's  parts  are  cleansed  and  the  solution  and  instruments 
rendered  sterile.  A  dram  or  two  or  olive  oil  is  injected  by 
means  of  a  glass  syringe  into  the  anterior  urethra.  If  a  metal 
catheter  is  used  the  procedure  is  as  follows:  The  patient  lies 
in  the  recumbent  position  with  his  head  resting  on  a  pillow,  the 
legs  slightly  flexed  and  the  thighs  separated.  The  surgeon  stands 
at  the  patient's  left  side.     The  penis,  with  the  foreskin  drawn 


Fig.  149. 


-The  first  stage  in  the  technic  or  catheterization. 
Surgery.) 


(Fowler's 


back,  is  grasped  with  the  left  hand.  The  catheter  is  held  in  the 
right  hand,  the  palm  of  the  latter  directed  toward  the  patient's 
feet.  The  beak,  of  the  instrument  is  introduced  with  its  shaft 
held  over  the  groin  and  almost  touching  the  skin,  until  it  passes 
the  penile  urethra  or  until  all  of  the  curve  and  an  inch  or  more 
of  the  shaft  has  disappeared.  Only  the  gentlest  pressure  is 
employed.  The  penis  is  drawn  over  the  catheter,  the  beak 
following  the  roof  of  the  canal.  As  the  extremity  of  the  catheter 
reaches  the  cul-de-sac  of  the  bulb,  as  determined  by  the  little 


216 


OPERATING  ROOM  AND  THE  PATIENT 


finger  of  the  hand  that  holds  the  penis,  the  instrument  enters 
the  membranous  portion  of  the  urethra,  thus  completing  the 
first  stage  of  the  operation  (Fig.  149). 

In  the  second  stage  the  handle  of  the  instrument  is  carried 
to  the  median  line.  The  shaft  is  kept  well  back  toward  the 
surface  of  the  abdomen,  almost  touching  the  latter.  As  the 
beak  adapts  itself  to  the  subpubic  curve  the  penis  is  released 
and  the  scrotum  grasped  in  the  hollow  of  the  left  hand,  while 


I'ig.   150. — The  second  stage  in  the  techxdc  of  catheterization.     (Fowler's 

Surgery.) 


at  the  same  time  the  parts  are  pressed  against  the  pubis  and 
upward  traction  made  (Fig.  150).  The  instrument  is  now 
gently  advanced  until  its  point  lies  well  against  the  pubis, 
when  the  scrotum,  testicles,  and  penis  are  released  and  the 
instrument  transferi'ed  to  the  left  hand. 

In  the  third  stage  the  instrument  is  steadied  in  the  median 
line  by  the  left  hand  and  its  shaft  carried  away  from  the  surface 
of  the  abdomen  (Fig.  151),  the  handle  describing  the  arc  of  a 
circle  during  this  part  of  the  manipulation.  This  movement  is 
to   be    continued    until    the   handle    of   the   instrument    almost 


GENERAL    CONSIDERATIONS    IN    THE    AFTER-TREATMENT     217 

reaches  the  meatus.  The  right  hand  now  makes  pressure  in  a 
downward  direction  on  the  root  of  the  penis  to  stretch  the 
suspensory  ligament  and  diminish  the  curve  of  the  membranous 
portion  of  the  urethra  (Fig.  152).  At  the  same  time  the  instru- 
ment is  depressed  between  the  thighs  and  sHps  into  the  bladder. 
The  entrance  of  the  instrument  into  the  bladder  is  announced 
by  a  flow  of  urine.     The  same  technic  applies  to  the  passage  of 


Fig.  151. — The  third  stage  in  the  technic  of  catheterization.  The 
instrument  has  been  carried  in  an  arc  of  a  circle  from  the  surface  of  the  abdo- 
men, while  at  the  same  time  it  has  been  advanced  still  further  into  the 
urethra.     (Fowler's  Surgery.) 

sounds.     The  entrance  of  the  latter  into  the  bladder  is  indicated 
by  the  ability  to  rotate  it  on  its  own  axis  in  all  directions. 

The  passage  of  a  metal  instrument  through  the  curved  portion 
of  the  canal  marks  the  most  difficult  stage  of' the  operation. 
The  beak  may,  at  the  moment  of  change  in  its  direction,  press 
the  bulb  too  far  down  by  prematurely  lowering  the  handle, 
so  that  the  wall  is  crowded  before  the  instrument.  Further 
progress  is  blocked  and  the  instrument  must  be  partially  with- 
drawn for  another  trial. 


218 


OPERATING    ROOM    AND    THE    PATIENT 


The  method  of  using  a  gum-elastic  catheter  armed  with  a 
stylet  does  not  differ  from  the  foregoing.  A  fiexible  catheter 
of  vulcanized  rubber  is  easily  passed,  under  normal  conditions, 
by  simply  ''feeding"  it  in,  a  half -inch  at  a  time. 

Following  catheterization  the  bladder  is  irrigated  with  a  pint  of 
warm  -1  per  cent,  boric  acid  solution  and  a  dram  or  two  of  5 
per  cent,  argyrol  solution  left  in  the  bladder.  If  a  two-current 
catheter  has  been  used  the  flow  of  irrigating  fluid  may  be  con- 


Fig.  152. — The  fourth  stage  in  the  technic  of  catheterization.  Ths 
instrument  is  depressed  between  the  thighs,  and  at  the  same  time  pressure 
is  made  at  the  root  of  the  penis  to  stretch  the  suspensory  Hgament  and 
diminish  the  curve  of  the  membranous  portion  of  the  urethra.  (Fowler's 
Surgery.) 

tinuous;  if  a  single  current  catheter  from  four  to  six  ounces  of 
the  solution  is  allowed  to  run  in  and  this  is  drawn  off  before 
introducing  more. 

Post -operative  Pneumonia. — ^May  result  from  exposure  of 
the  patient  while  under  the  anesthetic;  from  inspiration  of 
secretions  from  the  mouth  or  of  material  vomited  during  anes- 
thesia (foreign  body  pneumonia) ;  from  keeping  debilitated 
patients  too  long  confined  in  the  dorsal  position   (hypostatic 


GENERAL    CONSIDERATIONS    IN    THE    AFTER-TREATMENT     219 

pneumonia) ;  from  infection  carried  to  the  lung  through  the 
blood  (septic  pneumonia).  Aside  from  the  ordinary  con- 
tributing causes  of  pneumonia,  such  as  age,  alcoholism,  cachexia; 
cardiac  weakness,  and  weather  conditions,  the  disease  occurs 
more  frequently  after  operations  on  the  respiratory  apparatus; 
next  in  frequency  after  abdominal  operations,  particularly 
those  in  the  neighborhood  of  the  diaphragm.  Loss  of  blood 
predisposes  to  pneumonia. 

Treatment. — Preventive  treatment  consists  in  cleansing  the 
mouth,  throat,  and  nose  precedent  to  anesthetization;  in  keeping 
the  air-passages  free  during  anesthetization;  in  the  proper 
selection  and  preparation  of  patients  for  operation  (except  in 
imperative  cases  operations  should  be  deferred  in  the  presence  of 
any  respiratory  disease,  however  mild  its  character) ;  in  taking 
care  not  to  expose  the  patient  unnecessarily,  either  during  the 
anesthesia  or  while  the  patient  is  recovering  from  the  anesthetic 
(the  patient's  body  should  be  kept  dry  and  drafts  avoided) ; 
in  frequent  change  of  position  of  the  patient  during  the  after- 
treatment  to  avoid  hypostatic  pneumonia;  in  proper  care  of  the 
wound. 

The  treatment  of  the  disease  itself  consists  in  repeated  dry 
cupping  early  in  the  disease,  the  application  of  a  pneumonia 
jacket,  frequent  change  of  position  and  plenty  of  fresh,  cold  air. 
Oxygen  should  be  administered  in  cases  where  a  considerable  area 
of  lung  is  involved.  Drugs,  with  the  possible  exception  of  mas- 
sive doses  of  camphor  in  oil  by  hypodermic  (Seibert),  do  not 
seem  to  exert  any  influence  upon  the  disease  itself.  Ten-grain 
doses  of  carbonate  of  ammonia  or  of  guiacol  every  two  or  three 
hours  serve  to  somewhat  stimulate  the  heart  and  to  aid  the 
larger  air-passages  in  getting  rid  of  their  secretions. 

Cupping. — ^Wet  or  dry  cupping  may  be  used.  Wet  cupping, 
formerly  much  employed,  is  rarely  used  at  the  present  time.  Dry 
cupping  consists  in  causing  a  local  congestion  by  applying,  over 
the  area  where  it  is  wished  to  produce  congestion,  a  receiver 
from  which  the  air  has  been  exhausted.  Ordinary  glass  tumblers 
serve  as  well  as  special  cupping  glasses.  The  interior  of  the 
tumbler  is  moistened  with  a  little  alcohol  or  proof  whiskey.  To 
do  this,  twist  some  cotton  around  the  end  of  a  lead  pencil, 


220  OPERATING    ROOM    AXD    THE    PATIENT 

moisten  it  with  alcohol  and  rapidly  smear  the  interior  of  the 
tumbler  with  the  alcohol.  Light  the  alcohol  in  the  tumbler  with 
a  match,  and  apply  the  tumbler  quickly  to  the  area  indicated. 
The  stick  armed  with  cotton  that  has  been  saturated  with  alcohol, 
and  the  supply  of  alcohol,  that  was  used  for  saturating  the  cotton 
mop,  should  be  kept  at  a  distance  from  the  patient.  Care 
should  be  taken  not  to  smear  the  interior  of  the  tumbler  too 
profusely  with  alcohol,  otherwise  some  may  run  down  over  the 
edge  of  the  tumbler  and  burn  the  patient.  Several  of  these 
tumblers  may  be  used.  As  the  expanded  air  in  the  tumbler  cools, 
the  underlying  soft  parts  will  be  forced  by  the  outside  atmospheric 
pressure  up  into  the  tumbler,  and  so  congevstion  of  these  parts 
will  be  produced.  The  amount  of  congestion  will  vary  some- 
what with  the  length  of  time  (usually  a  few  minutes)  the  tumbler 
is  left  in  j^lace.  To  remove  the  tumbler,  press  the  skin-  down  with 
the  thumb  at  the  edge  of  the  glass  and  so  allow  the  air  to  enter; 
the  tumbler  may  then  be  readily  removed.  Glasses  with  sharp 
edges  should  not  be  employed,  as  they  may  cut  the  tissues  if  left 
long  in  position.  If  wet  cupping  is  employed,  the  above  pro- 
cedure should  be  first  carried  out,  and  then  the  congested  area 
may  be  scarified,  preferably  with  a  scalpel.  (In  former  times  a 
spring  scarificator  was  employed,  but  it  was  found  practically 
impossible  to  keep  the  blades  aseptic) .  The  cups  are  then  applied 
a  second  time,  and  the  suction  from  the  cups  causes  the  blood  to 
flow  from  the  scarified  area.  When  sufficient  blood  has  been 
drawn,  the  cups  are  removed  and  an  aseptic  dressing  is  applied. 

Hydremia. — ^It  is  possible  by  the  administration  of  too  much 
fluid  by  rectum,  by  hypodermoclysis  or  intravenously  to  cause 
so  marked  a  relative  increase  in  the  fluid  contents  of  the  blood 
that  the  tissues  become  "water  logged."  The  symptoms  are 
similar  to  those  of  shock  and  hemorrhage.  The  logical  treatment 
would  seem  to  be  cardiac  stimulation  and  direct  transfusion  of 
blood  to  lower  the  relative  increase  of  plasma. 

The  temperature  is  taken  every  four  hours  for  the  first  three 
days;  later  night  and  morning  in  ordinary  cases.  In  septicemia 
and  complicated  cases  the  temperature  is  taken  every  four  hours 
until  all  danger  is  past.  In  cases  of  beginning  septic  abdominal 
complications,  in  which  the  diagnosis  is  uncertain,  whether  opera- 


GENERAL    CONSIDERATIONS    IN    THE    AFTER-TREATMENT     221 

tive  or  under  observation,  the  temperature  is  taken  every  hour. 
Directly  after  the  operation  the  temperature  may  be  subnormal. 
This  may  occur  at  times  during  the  after-treatment.  Of  itself  it 
need  not  occasion  alarm.  If  the  wound  pursues  an  aseptic  course 
the  temperature  will  not  vary  to  any  marked  degree.  It  may  be 
normal  or  as  high  as  100°  F.,  but  will  pursue  an  even  course.  A 
slight  rise  to  100°  F.,  or  101°  F.  occurring  in  the  first  few  days 
prior  to  the  occurrence  of  a  bowel  movement  is  not  a  source  of 
anxiety.  The  cause  is  found  in  intestinal  fermentation.  This 
causes  an  autointoxication.  Autointoxication  may  not  be  due 
to  partial  reabsorption  of  excrementitious  matter  in  the  intestinal 
canal  alone,  but  may  also  be  due  to  lessened  activity  of  the  skin, 
lungs,  kidneys,  and  liver.  Should  the  tongue  be  furred,  breath 
bad,  a  bad  taste  in  the  mouth,  headache,  anorexia,  or  malaise 
be  present,  and  the  bowels  be  closed,  together  with  a  slight  rise  of 
temperature,  moving  the  bowels  promptly  causes  a  return  to  the 
normal  course.  During  the  first  twenty-four  hours  the  temper- 
ature may  rise  to  100°,  101°,  or  even  102°  F.  in  aseptic  cases. 
This  reactive  fever  is  commonly  known  as  aseptic  fever.  This  rise 
in  temperature  is  gradual;  reaches  its  maximum  in  a  few  hours, 
in  any  event  by  the  end  of  the  first  twenty-four  hours;  and  is 
rarely  accompanied  by  a  chill.  There  is  a  corresponding  in- 
crease in  pulse-rate.  The  patient's  face  is  flushed,  the  eyes  are 
bright,  and  there  is  more  than  the  usual  amount  of  thirst.  These 
symptoms  subside  in  a  few  hours,  or  in  any  case  by  the  end  of  the 
second  twenty-four  hours.  They  need  occasion  no  alarm.  There 
is  decidedly  less  reaction,  the  more  exact  thehemostasis.  Saline 
by  rectum  also  lessens  the  reaction.  Any  sharp  deviation  from 
the  normal  course  of  wound  temperature  is  to  be  regarded  with 
suspicion.  Normal  wound  temperature  may  not  be  normal  temper- 
ature in  the  usual  sense,  but  may  be  99°  to  100°F.  Actual  normal 
temperature,  98.4°  F.,  may  not  be  reached  until  the  tenth  day. 
A  slight  rise  of  temperature  indicating  a  slight  local  disturbance  is 
not  incompatible  with  primary  union.  Every  rise  of  temperature 
has  a  cause,  and  this  cause  must  be  sought  out  and  removed.  A 
rise  in  temperature  in  the  first  twenty-four  hours,  while  prob- 
ably due  to  the  absorption  of  nucleins  and  albumoses  (aseptic 
fever),  may  be  due  to  pneumonia,  bronchitis,  or  nephritis.     In  the 


222  OPERATING  ROOM  AND  THE  PATIENT 

latter,  however,  there  will  be  other  symptoms  which  will  lead  to 
a  correct  diagnosis.  Tension  of  the  pulse,  headache,  wandering 
delirium,  and  muscular  twitching  will  establish  the  diagnosis  of 
a  renal  lesion.  Physical  examination  of  the  chest  and  careful 
urinalysis  will  aid  in  establishing  the  cause  of  the  fever.  Fever 
occurring  after  a  lapse  of  two  or  three  days  indicates  superficial 
wound  infection,  if  the  bowels  have  moved.  If  not,  intestinal 
fermentation  may  be  ruled  out  by  moving  the  bowels.  Fever 
occurring  in  the  second  week  usually  indicates  infection  of  the 
deeper  tissues,  such  as  stitch  abscess.  Fever  due  to  causes  other 
than  those  mentioned  may  occur.  Operative  cases  have  no  more 
immunity  from  the  usual  causes  of  fever — ^typhoid,  malaria, 
diphtheria,  etc. — than  other  patients.  As  a  rule,  a  temperature 
which  continues  high,  associated  with  rapid  pulse  from  the  time 
of  operation,  indicates  severe  general  infection. 

The  pulse  should  be  just  as  carefully  watched  as  the  tempera- 
ture. Any  var'ation  from  the  normal  frequency,  rhythm,  and 
tension  is  noted.  It  is  studied  in  connection  with  the  tempera- 
ture. After  severe  operations  or  prolonged  anesthetizations  a 
rapid  pulse  is  the  rule.  This  may  persist  for  forty-eight  hours, 
but  so  long  as  it  does  not  increase  in  rapidity  and  so  long  as  the 
general  condition  of  the  patient  is  good  there  will  be  no  cause 
for  anxiety.  In  cases  pursuing  a  normal  wound  course  the  same 
relation  will  be  maintained  throughout  between  the  pulse  and 
the  temperature. 

The  respiration  is  also  carefully  watched  and  recorded.  It  is 
studied  in  its  relation  to  the  temperature  and  pulse.  Its  type, 
costal  or  abdominal;  depth,  deep  or  shallow;  rhythm,  regular 
or  irregular;  rate,  rapid  or  slow;  equality  of  expansion  of  each 
side  of  the  chest,  whether  painful  or  not;  and  its  other  charactei's 
are  noted.  If  any  variation  from  the  normal  occurs,  a  prompt 
search  for  the  cause  is  instituted.  Physical  examination  to  be 
thorough  must  include  not  only  the  anterior  and  lateral  chest 
wall,  but  also  the  posterior  region.  It  is  here  that  pneumonic 
processes  (hypostatic  pneumonia)  begin.  After  abdominal 
operations  the  respiratory  rate  may  be  increased  to  twenty- 
four  and  remain  so  for  several  days. 

Delirium  tremens  occurs  as  a  complication  following  injury  or 


GENERAL    CONSIDERATIONS    IN    THE    AFTER-TREATMENT     223 

operation  in  chronic  alcoholics.  It  more  often  occurs  in  whiskey 
drinkers  than  in  beer  or  wine  drinkers.  It  may  follow  even 
trivial  operations.  It  is  favored  by  digestive  disturbances  and 
the  fever  which  accompanies  wound  infection. 

Symptoms. — There  is  first  characteristic  restlessness,  followed 
by  hallucinations.  Examination  of  the  urine  shows  an  albumin- 
uria. There  is  marked  tremor  of  the  extremities.  It  may  occur 
a  short  time  after  the  operation,  or  not  until  two  or  three  days 
have  elapsed.  Insomnia  may  be  the  first  symptom.  The 
patient  is  nervous  and  talkative.  The  speech  is  confused. 
Mental  disturbances  are  mild  at  first,  later  they  become  more 
pronounced.  The  pulse-rate  is  increased  and  arterial  tension  is 
raised.  The  hallucinations  become  more  marked  and  it  becomes 
necessary  to  restrain  the  patient.  The  character  of  the  hallucin- 
ations differs;  some  patients  imagine  they  see  various  kinds  of 
animals,  others  imagine  that  some  danger  is  impending,  others 
that  they  are  at  their  regular  business.  The  hands  and  feet  are 
in  continuous  motion.  These  patients  are  insensitive  to  pain. 
The  disease  lasts  from  one  to  three  days.  In  favorable  cases 
this  excited  condition  is  followed  by  exhaustion,  and  the  patient 
finally  drops  into  a  deep  sleep,  from  which  he  awakens  much 
weakened  without  any  recollection  of  his  trouble.  In  many  cases 
the  patient  dies  from  exhaustion  or  acute  cardiac  dilatation. 

Treatment. — ^The  treatment  is  largely  preventive.  In  oper- 
ating upon  alcoholics  it  is  advisable  to  administer  a  fourth  of 
a  grain  of  morphin  sulphate  hypodermically,  thirty  minutes 
before  the  anesthetic.  This  not  only  causes  the  patient  to  take 
the  anesthetic  better,  but  tides  over  the  pain  of  the  operation 
and  the  period  of  excitement  which  accompanies  it.  Patients 
who  are  known  to  be  alcoholics  should  be  given  large  doses  of 
bromids,  and  large  quantities  of  water  both  by  mouth  and 
rectum.  Upon  the  appearance  of  restlessness,  increased  tension 
of  the  pulse,  and  tremor  of  the  hands  an  intravenous  saline 
infusion  of  from  thirty  to  forty  ounces  should  be  given.  This 
acts  by  increasing  the  elimination  of  the  skin  and  kidneys  and 
diluting  the  toxemia.  It  will  usually  suffice  to  abort  the  attack 
(Warbasse),  Whiskey  may,  in  moderate  doees,  be  given  by 
mouth.     Sudden  abstinence  in  chronic  alcoholics  seems  to  favor 


224  OPERATING    ROOM    AND    THE    PATIENT 

the  occurrence  of  delirium  tremens.  In  such  cases  it  is  well  to 
give  some  whiskey  during  the  entire  course  of  the  after-treat- 
ment. Capsicum  and  digitalis  are  useful.  Chloral  hydrate  is 
given  for  insomia.  Should  the  case  go  on  to  delirium,  opium  is 
employed  and  the  patient  restrained;  otherwise,  as  these  patients 
have  no  sense  of  pain,  they  may  do  themselves  injury.  The  oper- 
ated part  should  be  protected  by  plaster  of  Paris  in  the  case  of 
operations  upon  the  extremities,  or  by  adhesive-plaster  strap- 
ping in  operations  upon  the  trunk.  Chronic  alcoholics  should  be 
gotten  out  of  bed  as  soon  as  possible.  They  should  be  watched  for 
the  first  symptoms  of  delirium  tremens.  In  such  cases  it  is  par- 
ticularly important  to  see  that  each  organ  of  the  body  carries 
on  its  function  properly,  the  bowels  should  be  thoroughly  moved 
daily,  the  skin  cleansed  daily,  easily  digested  food  and  a  maxi- 
mum amount  of  fluids  should  be  given,  the  latter  by  hypodermo- 
clysis  if  sufficient  fluid  cannot  otherwise  be  taken. 

Toxemia  following  Operations. — ^The  cause  for  faulty  met- 
abolism, evidenced  by  a  fairly  constant  train  of  symptoms 
following  operations,  is  unknown.  We  see  cases  presenting  the 
symptoms  of  headache,  malaise,  nausea  and  sometimes  vomiting. 
Urinary  examination  of  these  cases  shows  a  decided  increase  in 
the  daily  amount  of  uric  acid,  as  shown  by  the  lowered  urea  and 
uric  acid  ratio  and  the  presence  of  acetone,  diacetic  acid,  and 
sometimes  beta-oxybutyric  acid.  In  other  cases  there  is  a 
decided  increase  in  the  daily  excretion  of  indoxyl-sulphate  and 
skatoxyl-sulphate,  as  shown  by  the  presence  of  indican  and 
skatol  in  the  urine  and  a  lowered  ratio  of  mineral  and  ethereal 
sulphates.  The  urine  may  present  a  combination  of  both  these 
characteristics. 

Acidosis  follows  operation  in  a  certain  proportion  of  cases. 
It  is  favored  by  vigorous  catharsis  and  deprivation  of  fluids 
before  operation.  The  same  conditions  favor  its  occurrence 
following  operation.  Lord  and  Osgood  in  1907  showed  that 
acetonuria  occurred  in  88.5  per  cent,  in  173  ether  anesthesias 
•  by  the  cone  method  while  it  only  occurred  in  26  per  cent,  of  a 
series  of  222  ether  anesthesias  by  the  drop  method.  Conti  in 
1895  first  called  attention  to  acetonuria  after  anesthesia.  The 
complication  is  prevented  by  the  free  administration  of  fluids 


CARE    OF    THE    WOUND  225 

before  and  after  anesthesia.  If  free  fluids  by  mouth  are  contra- 
indicated  then  saline  should  be  given  by  rectum  by  the  Murphy 
method.  Upon  the  occurrence  of  acidosis,  alkalines  in  large 
doses  are  indicated.  A  teaspoonful  of  bicarbonate  of  soda  in 
8  oz.  of  water  is  given  every  two  to  three  hours  by  mouth. 
Enough  bicarbonate  of  soda  is  added  to  the  Murphy  proctoclysis 
to  make  a  2  per  cent,  solution.  In  very  emergent  cases  repeated 
hypodermoclyses  of  2  per  cent,  solution  of  bicarbonate  of  soda 
are  indicated. 


CHAPTER  VII. 
CARE  OF  THE  WOUND. 

General  rules.  Aseptic  wounds.  Revision  of  dressings.  Normal  course 
of  wounds  healing  per  primam.  Primary  dressing.  Redressing.  Technic 
of  removal  of  skin  sutures.  The  second  dressing.  Drainage.  Aseptic 
wounds  healing  per  secundam.  Secondary  suturing.  Infection  of  the 
wound.  Aseptic  fever.  Intestinal  fermentation.  Immediate  infection. 
Early  infection.  Late  infection.  Stitch  abscess.  Retention  of  secretion. 
Retention  of  secretions  with  tension.  Subcutaneous  phlegmon.  Tendinous 
phlegmon.  Diffuse  cellular  infiltration.  Infection  in  loose  cellular  tissue. 
Aseptic  wounds  in  infected  tissues.  Retention  of  secretion  from  blockage 
of  the  drain.  Removal  of  gauze  drains.  Irrigation  of  cavities.  Disturb- 
ance of  granulation.  Sluggish  granulation.  Exuberant  granulation. 
Pyogenic  membrane.  Indolent  wounds.  Direct  sunlight.  Treatment  of 
varicose  ulcer.  Sinus.  Thermocautery  wounds.  Care  of  the  skin  in  the 
neighborhood  of  the  wound.  Vaccine  therapy  of  infection.  Antitoxins. 
Bier's  hyperemia.     Bismuth  paste. 

General  Rules. — Local  rest  of  the  part  must  be  maintained 
until  healing  is  complete.  General  rest  is  only  necessary  when 
body  movements  would  interfere  with  the  local  rest  of  the 
wound. 

Aseptic  Wounds.  Revision  of  Dressings. — ^The  dressing  should 
be  inspected  frequently  and  at  once  revised  if  displaced.  Revi- 
sion should  not  include  inspection  of  the  wound  unless  the 
wound  has  become  exposed.  Too  early  inspection  favors  in- 
fection. 

Normal  Course  of  Wounds  Healing  per  Primam. — ^A  wound 
aseptically  made  usually  heals  without  complications,  though 
cultures  taken  from  wounds  will,  in  50  per  cent,  of  cases  grow, 

"15 


226  OPERATING    ROOM    AND    THE    PATIENT 

i.e.,  one-half  of  such  wounds  contain  infective  agents.  In  the 
course  of  five  to  seven  days  skin  union  has  occurred.  In  por- 
tions of  the  body  subject  to  strain,  union  is  not  firm  before  the 
tenth  to  the  fourteenth  day.  Age  is  a  factor  in  the  healing  of 
skin  wounds  as  in  wounds  of  other  tissues;  in  elderly  persons, 
skin  wounds  heal  slowly;  in  young  children,  very  rapidly.  The 
blood  and  lymphatic  supply  of  the  part  plays  an  important  role; 
wounds  of  the  face  heal  in  five  days^  as  here  the  blood  and 
lymphatic  supply  is  very  rich;  wounds  of  other  parts  are  slower 
in  healing.  The  healing  process  in  the  deeper  structures,  i.e., 
the  muscular  and  fascial  layers,  is  slower  than  in  the  skin;  from 
ten  to  fourteen  days  being  necessary  before  moderately  firm 
union  is  accomplished.  The  extent  of  the  wound  is  a  factor  in 
healing.  Small  wounds  heal  more  readily  than  large  wounds. 
Practically  we  can  say  that  a  wound  in  any  part  of  the  body 
involving  the  soft  parts  is  healed  on  the  fourteenth  day.  Such  a 
wound,  however,  must  not  be  subjected  to  strain,  as  the  union  is 
still  fresh.  Complicating  diseases,  particularly  anemia,  syphilis, 
diabetes  and  tuberculosis  delay  wound  healing. 

The  primary  dressing  may  be  an  occlusive  or  an  absorptive  one. 
The  common  form  of  occlusive  dressing  is  collodion,  either  alone 
or  in  combination  with  cotton  or  gauze  extending  beyond  the 
w^ound  for  a  space  of  two  inches  in  all  directions.  It  does  not 
provide  for  the  absorption  of  any  considerable  wound  secretion 
and  should  only  be  used  in  wounds  in  which  hemostasis  has  been 
exact  and  in  which  discharge  is  not  expected.  The  contiguous 
integument  should  be  thoroughly  cleansed,  the  wound  care- 
fully dried,  and  the  edges  approximated.  The  collodion  is 
applied  with  a  camel's  hair  pencil,  minute  pieces  of  fluffed  out 
cotton  being  added  from  time  to  time.  Several  layers  of  ab- 
sorbent cotton  or  gauze  may  be  mingled  with  the  collodion,  and 
the  area  thus  covered  may  be  quite  extended.  Iodoform  and 
other  medicaments  are  sometimes  mixed  with  collodion,  but 
little  if  any  advantage  can  be  claimed  for  these  combinations. 
The  presence  of  fluid  beneath  this  dressing  is  suggestive  of 
present  or  impending  infection  and  should  prompt  its  quick 
removal,  absorptive  dressing  being  employed  instead. 

When  discharge  is  expected  an  absorptive  dressing  is  indicated, 


CARE    OF    THE   WOUND  227 

such  as  dry  sterile  plain  gauze  shaken  out  and  applied  loosely 
over  the  wound  covering  the  surrounding  surface  for  at  least 
six  inches  so  that  the  wound  is  thoroughly  protected  by  a  soft 
and  comfortable  dressing,  retained  in  place  by  strips  of  zinc  oxid 
plaster  and  a  suitable  bandage  or  binder. 

Redressing  is  done  on  the  fifth  day  in  wounds  of  the  head  and 
neck;  on  the  seventh  day  in  wounds  of  other  parts,  at  which 
time  the  superficial  sutures  are  removed.  Without  indication 
a  wound  expected  to  heal  per  primam  should  not  be  dressed 
earlier.  The  principle  of  rest  to  the  wound  and  infrequent 
dressings  should  be  remembered.  Only  too  often  it  happens 
that  meddlesome  interference  with  the  dressing  on  the  third  or 
fourth  day  results  in  infection.  At  this,  as  at  all  dressings,  the 
wound  and  the  skin  in  its  neighborhood  should  not  be  touched 
by  the  hand.  All  manipulations  are  done  with  sterile  instru- 
ments and  sponges.  No  irrigation  is  used.  Just  as  much  care 
in  the  preparation  of  the  hands,  in  the  isolation  of  the  wound  by 
sterile  towels,  and  in  the  sterilization  of  instruments  and  gauze, 
is  employed  as  at  the  orginal  operation.  It  is  unnecessary, 
however,  that  the  hands  be  disinfected  preparatory  to  each  dress- 
ing if  rubber  gloves  are  properly  donned.  These  are  easiest  put 
on  in  a  dry  state  with  the  gauntlet  turned  back  for  two  inches. 
The  left  glove  is  grasped  by  the  fingers  of  the  right  hand,  taking  a 
firm  grip  on  the  anterior  surface  of  the  cuffed  gauntlet.  The 
left  hand  is  then  inserted  into  the  glove  and  if  the  hand  is  dry 
and  well  powdered  the  glove  will  at  once  be  drawn  smoothly  on 
the  hand.  The  right  glove  is  then  picked  up  and  donned  in  a 
similar  manner  by  the  left  hand,  taking  care  to  keep  the  fingers 
beneath  the  cuffed  portion  of  the  glove.  The  wish  to  give  the 
wound  rest  and  not  to  interfere  with  the  healing  process  must 
not,  however,  delay  the  dressing  when  indicated. 

The  bandage  and  outer  layers  of  the  dressing  are  removed 
without  touching  that  next  the  wound.  The  final  layer  of 
dressing  is  removed  with  forceps  in  the  direction  of  the  long 
axis  of  the  wound  so  as  to  occasion  least  pain  and  not  to  weaken 
the  union.  The  wound  appears  as  a  thin  line  marked  by  the 
dark,  thin  blood  clot  lying  between  its  lips. 

Technic  of  Removal  of  Skin  Sutures. — If  a  subcuticular  suture 


228  OPERATING    ROOM    AND    THE    PATIENT 

has  been  used,  one  end  is  caught  by  thumb  forceps  and  slight 
traction  is  made  until  it  is  removed  from  its  bed  for  one  quarter 
of  an  inch  where  it  is  cut.  The  other  end  of  the  suture  is  caught 
with  forceps  and  removed  by  traction  in  the  long  axis  of  the 
wound.  At  the  point  of  emergence  of  the  suture  there  will 
usually  exude  a  single  drop  of  blood;  this  is  sponged  away 
without  allowing  the  fingers  to  come  in  contact  with  that  j)art 
of  the  sponge  which  touches  the  wound.  If  the  suture  does 
not  come  away  readily  and  there  is  danger  of  breaking  the  thread 
by  more  pronounced  traction,  it  may  be  left  for  twenty-four  or 
forty-eight  hours  longer,  A  dressing  similar  to  the  original 
dressing  is  applied.  If  individual  sutures  or  a  chain  stitch  has 
been  used,  each  stitch,  or  in  the  case  of  the  chain  stitch,  each 
section  of  suture,  is  to  be  raised,  cut  and  removed.  If  inspection 
shows  that  wound  healing  is  not  firm  the  sutures  may  be  left 
for  a  day  or  two  longer,  or  the  wound  may  be  supported  by 
sterile  strips  of  adhesive  plaster. 

The  second  dressing  is  done  on  the  tenth  to  the  fourteenth 
day.  In  small  wounds  in  parts  other  than  the  abdomen  the 
tenth  daj^  is  the  usual  time  for  the  removal  of  through-and- 
through  sutures,  using  the  same  technic  as  in  the  removal  of 
individual  skin  sutures.  In  small  abdominal  wounds  the 
sutures  may  be  removed  on  the  tenth  day.  In  more  extensive 
wounds  they  are  removed  on  the  fourteenth  day,  or,  as  in  cases  of 
extensive  ventral  hernise,  even  later  where  tension  is  great.  A 
loose  suture  means  that  it  is  no  longer  serving  its  purpose  in 
securing  apposition  of  the  wound  edges  and  so  should  be  removed. 
If  buried  sutures  have  been  employed  the  wound  is  inspected  on 
the  tenth  to  the  fourteenth  day,  and  the  young  scar  supported 
by  adhesive  plaeter  if  in  a  part  subjected  to  strain. 

Drainage  is  indicated  in  aseptic  wounds  in  which  a  dead 
space  has  been  left  which  cannot  be  closed  by  suitable  pressure 
of  the  dressings  or  in  which  large  areas  have  been  exposed 
from  which  serous  discharge  may  be  expected.  Drainage  is 
provided  for  by  strips  of  green  silk  protective,  gauze  or  tubes. 
Such  wounds  heal  practicalh^  per  primam  and  their  treatment 
differs  only  in  the  treatment  of  the  drain.  The  wound  is  in- 
spected at  the  end  of  twenty-four  hours  and  the  amount  of 


CARE    OF    THE    WOUND  229 

serous  discharge  noted.  Should  the  discharge  be  continuing  and 
the  drain  not  clogged  up,  it  is  only  necessary  at  this  dressing  to 
renew  the  copious  gauze  dressing  which  has  covered  such  a 
wound.  A  dressing  of  this  kind  should  be  done  daily  until  the 
serous  discharge  is  reduced  to  a  minimum.  Usually  the  dis- 
charge has  ceased  at  the  end  of  twenty-four  or  at  most  forty- 
eight  hours  and  the  drain  may  be  removed  and  the  wound  not 
dressed  again  until  the  seventh  day.  Should  it  be  found  that  the 
serous  discharge  has  become  somewhat  thickened  without 
entirely  ceasing  and  that  the  albumin  has  coagulated  on  the 
drain  and  so  reduced  its  draining  power,  the  drain  must  be 
renewed  and  again  inspected  at  the  end  of  twenty-four  hours. 

Aseptic  Wounds  Healing  per  Secundam. — Wounds  in  which 
cavities  exist  which  could  not  be  obliterated  by  pressure  and 
of  such  an  extent  as  to  require  granulation  tissue  to  fill  them 
are  usually  packed.  The  primary  tamponade  should  cause 
gentle  even  pressure  upon  all  parts  of  the  cavity.  There  is 
considerable  escape  of  serum  necessitating  a  change  of  the  outer 
dressing  at  the  end  of  twenty-four  or  forty-eight  hours.  The 
tamponade  if  unclogged,  is  not  changed  for  three  or  four  days. 
The  packing  is  then  removed  and  unless  there  is  damming  back 
of  secretion  a  new  packing  is  immediately  introduced.  Dis- 
charges lying  upon  the  surface  of  the  wound  are  carefully 
sprayed  away  with  a  mild  antiseptic  solution  in  an  atomizer, 
and  the  wound  surface  dried.  Redressings  should  be  done 
every  twenty-four  or  forty-eight  hours  according  to  the  amount 
of  wound  discharge.  When  the  shape  and  situation  of  the 
wound  permit,  tamponade  should  be  discontinued  and  strapping 
or  secondary  suture  done. 

Secondary  Suturing. — Secondary  suturing  is  indicated  in 
wounds  which  are  healing  by  granulation  and  in  which  the 
wound  is  clean,  particularly  when  such  wounds  occur  in  the 
neighborhood  of  joints  or  in  places  where  large  areas  of  cicatricial 
tissue  are  undesirable.  Even  if  it  is  not  possible  to  obtain 
accurate  apposition  of  the  wound  surfaces,  still  healing  occurs 
more  rapidly  and  a  stronger  cicatrix  is  obtained.  It  should  be 
performed  as  soon  as  the  wound  is  clean  and  before  profuse 
granulation  has  occurred.     The  surfaces  of  the  wound  should  be 


230  OPERATING    ROOM    AND    THE    PATIENT 

as  accurately  coapted  as  possible.  It  is  especially  necessary 
that  the  deeper  parts  of  the  wound  should  be  coapted  accurately. 
This  is  accomplished  by  passing  the  sutures  deeply,  taking  in 
the  depths  of  the  wound.  It  may  be  necessary  to  freshen  the 
edges  of  the  wound  and  to  curette  away  profuse  granulations. 
If  there  is  much  tension  of  the  skin,  lateral  incisions  under  the 
skin  with  loosening  up  of  the  skin  flaps  is  permissible,  alwaj^'s 
providing  that  there  is  no  infection  present.  After  freshening 
the  wound  surfaces  pressure  should  be  exerted  until  oozing  has 
stopped.  Wounds  secondarily  sutured  should  be  dressed 
every  two,  three,  or  four  days,  according  to  the  amount  ■  of 
discharge.  Such  wounds  are  more  prone  to  disturbance  of 
granulation,  particularly  to  exuberant  granulations,  than 
primarily  clean  wounds.  The  treatment  of  the  disturbances 
of  healing  is  the  same  as  in  other  wounds. 

Infection  of  the  Wound. — Mild  infection  may  occur  without 
fever,  and  with  only  slight  evidence  of  local  disturbance.  The 
patient  may  complain  of  slight  pain  in  the  v/ound.  In  all  wounds 
there  is  some  pain  for  the  first  few  hours  following  an  operation. 
This  pain  subsides  at  the  end  of  twenty-four  hours  only  to  recur 
if  the  parts  are  moved.  Pain  occurring  after  the  subsidence  of 
primary  wound  pain  is  to  be  regarded  as  an  evidence  of  infection. 
This  pain  is  caused  by  a  swelling  of  the  wound  which  causes  the 
sutures  to  press  upon  the  parts.  In  more  marked  infection, 
fever,  pain,  general  depression,  loss  of  appetite  and  headache 
may  develop.  Of  these  sjanptoms,  fever  and  pain  are  the 
most  common.  Even  if  the  fever  is  absent,  however,  infection 
cannot  be  excluded  for  the  pus  focus  may  be  well  walled  off. 
This  is  the  case  in  infection  having  its  origin  in  a  ligature  acting 
as  a  foreign  body.  In  such  cases  fever  is  delayed  until  the  focus 
has  enlarged  considerably,  while  the  recognition  of  such  a  con- 
dition may  not  be  possible  until  it  has  approached  the  surface. 
The  presence  of  both  the  symptoms  of  pain  and  fever  makes  the 
diagnosis  of  infection  certain.  The  occurrence  of  one  makes  the 
diagnosis  probable.  A  sudden  rise  of  temperature  marks  the 
development  or  the  extension  of  infection.  So-called  aspetic 
fever  must  not  be  mistaken  for  wound  infection.  Aseptic  fever 
occurs  during  the  first  twenty-four  hours  following  the  operation; 


CARE    OF    THE    WOUND  231 

the  rise  of  temperature  is  gradual,  rarely  going  above  102°  F.  It 
reaches  its  maximum  twenty-four  hours  after  the  operation  and 
quickly  subsides,  rarely  persisting  beyond  forty-eight  hours. 
It  need  occasion  no  anxiety.  The  character  of  the  operation  will 
enter  somewhat  into  the  amount  of  aseptic  or  reactive  fever. 
In  cases  requiring  extensive  dissection,  or  in  which  the  tissues 
have  been  exposed  for  a  considerable  length  of  time,  aseptic 
fever  is  more  apt  to  occur.  Another  cause  for  fever  is  intestinal 
fermentation.  In  every  case  of  fever  following  operation  the 
condition  of  the  bowels  should  be  inquired  into,  and  if  they  have 
not  moved  freely,  a  laxative  should  be  given  except  in  operations 
upon  the  gastrointestinal  tract  in  which  case  an  enema  is  in- 
dicated. If  the  fever  is  due  to  constipation  or  fermentation,  a 
thorough  evacuation  of  the  bowels  will  cause  the  temperature  to 
subside.  Continued  fever,  with  acceleration  of  the  pulse,  and 
interference  with  the  general  condition  of  the  patient  always  calls 
for  an  inspection  of  the  wound.  The  symptoms  will  vary  with 
the  virulence  of  the  infection  and  the  resistance  of  the  tissue.  If 
there  is  free  drainage  and  an  abundant  absorptive  dressing  as  is 
the  case  in  wounds  healing  per  secundam,  there  will  be  but 
slight  absorption,  and  in  spite  of  the  occurrence  of  infection  the 
general  symptoms  will  not  be  marked.  In  wounds  completely 
sutured  even  the  occurrence  of  slight  infection  may  cause  general 
symptoms.  Upon  the  institution  of  free  drainage  the  symptoms 
usually  subside  though  it  must  be  remembered  that  the  simplest 
infection  may  result  fatally. 

Clinically,  infection  is  designated  as  immediate,  early  and  late. 
In  immediate  infections  high  temperature,  rapid  pulse  and  the 
rapid  invasion  of  sepsis  begin  at  once  following  the  operation. 
Fortunately,  such  a  state  of  affairs  is  rare  and  can  be  traced  to  a 
preventable  cause,  errors  in  aseptic  technic.  Early  infection 
occurs  from  the  third  to  the  seventh  day  following  the  operation 
and  is  usually  superficial.  Upon  changing  the  dressing  a  slight 
redness  of  the  edges  of  the  incision  or  in  the  neighborhood  of  the 
stitch  holes  is  seen.  As  a  rule,  this  readily  subsides  following  the 
removal  of  the  superficial  sutures,  or  if  this  is  not  desirable  a 
compress  wet  with  mild  alcohol-bichlorid  solution  may  be  applied 
to  the  wound.     This  is  changed  daily,  kept  moist  and  its  evap- 


232  OPERATIXG  ROOM  AXD  THE  PATIENT 

orating  qualities  not  interfered  with.  In  other  infections,  also 
of  a  mild  nature,  but  slightly  more  marked  than  the  preceding, 
upon  the  removal  of  the  dressing  there  is  found  in  addition  to  the 
redness  of  the  wound  edges  a  drop  or  two  of  pus  exuding  either 
from  the  incision  or  from  the  suture  holes,  though  for  the  most 
part  the  wound  is  healed.  Both  these  mild  forms  of  infection 
are  due  to  bacteria  in  the  depths  of  the  skin  itself,  notably  the 
staphjdococcus  epidermis  albus.  These  bacteria  are  lodged  so 
deeply  in  the  skin  that  it  is  practically  impossible  to  eliminate 
them.  Fortunately,  not  only  are  they  of  little  infective  strength, 
but  the  skin  itself  is  possessed  of  a  high  degree  of  resisting  power. 
Removal  of  the  skin  suture  at  the  site  of  infection,  thus  providing 
free  drainage,  and  the  application  of  alcohol-bichlorid  solution 
w^ill  usually  suffice  to  allay  the  inflammation.  Should  there  be 
any  tendency  of  the  infection  to  spread,  the  entire  skin  wound 
should  be  opened.  Even  when  all  the  suture  holes  and  the  entire 
skin  wound  are  infected,  the  deeper  portions  may  remain  free 
from  infection  and  healing  in  that  part  of  the  wound  proceed 
uneventfully.  In  such  cases  the  superficial  parts  are  red  and 
swollen  and  pus  exudes.  The  sutures  are  seen  imbedded  in  the 
swollen  soft  parts,  the  skin  edges  are  glued  together  by  a  sticky 
exudate,  a  feeling  of  tension  in  the  wound  will  be  complained  of, 
and  there  will  be  slight  evening  rise  of  temperature.  Healing 
may  occur  with  only  very  slight  separation  of  the  wound  if  the 
sutures  are  removed  as  soon  as  infection  is  discovered.  The 
wound  should  be  gently  sprayed,  gently  dried  and  lightly  packed. 
Too  vigorous  cleansing  is  undesirable.  Small  adhesive-plaster 
strips  may  be  used  to  reinforce  the  wound  edges,  the  support  of 
which  is  weakened  by  removal  of  the  sutures.  If  pain  and  fever 
are  at  all  marked  the  entire  skin  wound  must  be  opened  up  and 
fiee  drainage  provided  for.  In  other  cases  it  is  only  necessary 
to  separate  the  wound  edges  at  the  points  where  pus  exudes, 
spray  away  the  pus  and  by  small  pledgets  of  gauze  insure  drain- 
age. Rapid  healing  may  be  secured  in  such  cases  by  careful 
and  frequent  dressings. 

Still  another  variety  of  mild  infection  is  shown  in  cases  in 
which  there  is  oozing  of  blood  under  the  skin.  This  predisposes 
to  infection.     The  prevention  is  thorough  hemostasis.     In  the 


CARE    OP    THE    WOUND  233 

early  stages  blood  may  escape  from  between  the  wound  edges; 
later  skin  healing  becomes  complete  and  the  swelling  develops 
as  a  hematoma  under  the  skin.  Such  effusion  of  blood  becomes 
in  part  absorbed  and  in  part  organized.  Should  infection  occur 
the  clot  breaks  down  and  the  usual  symptoms  of  infection  follow. 
In  infections  of  this  character  the  wound  should  be  opened  suffi- 
ciently to  thoroughly  express  and  wash,  out  all  of  the  infected 
clot.  The  resulting  cavity  is  then  lightly  packed.  As  a  rule, 
rapid  healing  results. 

In  aseptic  wounds  in  which  drainage  has  been  used  infection 
is  shown  by  an  increase  in  the  amount  of  discharge  and  a 
change  in  its  character  from  serum  to  sero-pus  and  finally  to 
pus. 

Late  Infection. — ^Late  infection  manifests  itself  during  the 
second  week.  It  is  usually  a  deep  infection.  Starting  in. the 
neighborhood  of  the  aponeurotic  structures  of  the  wound,  the 
clinical  course  of  the  wound  thus  infected  is  as  follows:  Healing- 
proceeds  apparently  uneventfully  until  some  time  between  the 
seventh  and  fourteenth  day,  when  a  sudden  rise  of  temperature 
shows  that  infection  has  taken  place.  It  may  be  that  at  the 
removal  of  the  skin  sutures  on  the  seventh  day  absolutely  no 
evidence  of  infection  was  apparent.  Some  days  later,  when  the 
temperature  rises  and  the  wound  is  again  inspected  to  see  if  the 
cause  for  the  increased  temperature  resides  there,  careful 
inspection  will  show  a  swelling  of  the  wound  which  originates 
in  the  deeper  parts  of  the  wound.  Except  for  this  swelling  the 
superficial  parts  will  appear  normal.  Such  an  infection  may  occur 
at  a  much  later  date,  even  four  to  six  weeks  after  wound 
healing  has  apparently  become  complete.  For  this  reason  it  is 
advisable  to  instruct  patients  to  report  immediately  upon  the 
occurrence  of  any  strange  sensations  or  appearance  of  swelling. 
This  very  late  deep  infection  is  caused  either  by  an  infected 
piece  of  suture  or  ligature  material  or  by  a  piece  of  suture  or 
ligature  material  which  fails  to  become  absorbed  and  which 
produces  a  foreign  body  suppuration.  Such  infections  may  also 
be  due  to  deep  hematomas,  the  result  of  inefficient  hemostasis. 

Treatment  consists  in  passing  a  narrow  bladed  pair  of  anatom- 
ical forceps,  closed,  to  the  center  of  the  swelling  and  withdrawing 


234  OPERATING    ROOM    AXD    THE    PATIEXT 

tliem  while  separating  the  blades.  This  allows  of  the  escape  of 
the  infection  through  the  tract  made  by  the  forceps.  The  open- 
ing should  be  enlarged  sufficiently  to  permit  of  free  drainage,  a 
small  rubber  tube  is  introduced  for  the  first  few  days.  When  the 
discharge  diminishes  this  is  replaced  by  gauze  drainage  or 
strips  of  green  silk  protective.  If  the  superficial  parts  are  firmly 
healed  the  infection  must  be  opened  with  a  scalpel. 

The  treatment  of  such  an  infection  should  be  initiated  upon 
its  discover}'.  It  is  futile  to  wait,  in  the  vain  hope  that  the 
swelling  wiU  subside.  If  not  opened  early  the  infection  spreads 
and  results  in  a  subcutaneous,  muscular  or  tendinous  phlegmon 
according  to  the  structure  involved. 

Stitch  Abscess. — Stitch  abscesses  are  either  superficial  or  deep. 
The  superficial  are  caused  by  the  staphylococcus  epidermis 
albus;  the  deep  may  be  caused  by  this  germ  being  carried  to 
the  deeper  portions  of  the  wound  by  the  passage  of  the  needle, 
but  are  C[uite  apt  to  be  deep  infections  endeavoring  to  find  an 
exit  along  the  suture.  One  suture  only  may  be  involved  or  all 
the  sutures  may  be  involved.  Should  the  wound  itself  partake 
in  the  suppurative  process,  this  must  be  opened  up,  offending 
sutures  removed,  and  each  stitch  abscess  opened  up  into  the 
wound,  the  bridge  of  skin  between  the  stitch  abscess  and  the 
wound  proper  being  incised,  thus  connecting  the  two.  Necrotic 
and  infected  tissues  should  be  curetted  away,  and  the  wound 
cleansed  with  the  peroxid  of  hydrogen  spray,  and  lightly  packed 
with  gauze  wrung  out  of  an  antiseptic  evaporating  solution. 
Should  the  wound  itself  not  be  infected,  each  stitch  abscess  is 
to  be  treated  as  an  independent  infection,  the  stitch  removed, 
the  abscess  opened,  curetted  and  cleansed.  The  evaporating 
dressing  should  be  kept  moist.  Here  as  in  all  infections  the  gen- 
eral rule  must  be  followed  as  closely  as  the  conservation  of  im- 
portant structures  will  allow — the  surface  opening  must  be  at 
least  of  the  same  size  as  the  depth  of  the  wound. 

Retention  of  Secretions. — ^If  only  a  portion  of  the  secretion 
flows  away,  the  remainder  will  stagnate  in  the  wound  and  fever 
will  result.  The  surface  signs  of  inflammation  will  be  slight,  and 
if  the  stagnation  is  in  the  deeper  portion  of  the  wound  these 
symptoms  may  be  absent.     There  will  be  but  slight  pain  on 


CARE    OF    THE    WOUND  235 

account  of  the  absence  of  tension.  If  the  secretions  infiltrate 
the  tissues,  or  if  there  is  no  exit  for  them,  the  pain  will  be  marked 
and  the  general  disturbance  will  be  greater.  The  pain  varies 
from  the  pain  of  mild  tension  to  a  constant,  agonizing  throbbing 
pain  which  is  increased  by  pressure  or  by  movement.  Fever  may 
occur  in  an  open  superficial  wound,  even  if  there  is  no  marked 
infection,  in  case  the  secretions  are  not  absorbed  by  the  dressing. 
In  such  cases  frequent  dressings  are  indicated.  Upon  changing 
the  dressing  the  thick  secretions  will  be  found  bathing  the  wound 
surface.  It  may  be  necessary  to  change  the  dressings  in  such  a 
case  two  or  even  three  times  a  day.  Moist  evaporating  absorbent 
antiseptic  dressings  will  decrease  the  infection.  The  free  evap- 
oration of  the  secretions  must  not  be  interfered  with. 

Retention  of  Secretions  with  Tension. — Here  we  have  all  the 
symptoms  of  abscess  or  phlegmon.  The  suture  which  overlies 
the  point  of  greatest  tension  must  be  removed  and  an  outlet 
provided  for  the  escape  of  the  retained  secretions.  If  the  removal 
of  several  sutures  does  not  provide  adequate  drainage,  and  the 
general  symptoms  continue,  more  sutures  are  to  be  removed  at 
a  subsequent  dressing.  Free  escape  of  secretions  is  essential. 
This  is  aided,  as  in  the  case  of  stagnation  of  secretions,  by  em- 
ploying an  evaporating  antiseptic  solution  to  moisten  the  gauze, 
thus  increasing  the  rapidity  of  the  evaporation  of  the  discharge. 
There  is  the  same  necessity  for  frequent  change  of  dressing.  Such 
dressings,  however,  should  not  be  employed  until  adequate 
drainage  has  been  provided.  As  soon  as  the  discharge  lessens 
dry  ganize  dressings  are  employed.  Should  the  local  condition 
not  subside  under  this  treatment,  the  entire  wound  must  be 
opened  up  and  loosely  packed  with  gauze.  It  may  be  necessary 
to  make  counter  openings.  In  wounds  involving  cavities,  even 
the  opening  of  the  entire  wound  may  not  provide  adequate 
drainage,  as  in  the  case  of  tuberculous  bone  disease  or  empyema 
thoracis,  in  which  event  a  second  operation  may  be  necessary. 

Phlegmon.  Spreading  Infection. — ^Whenever  infection  occurs 
there  is  always  a  possibility  of  its  spreading.  If  the  wound 
secretions  have  free  exit  the  tendency  to  spread  is  slight.  Even 
in  such  a  case,  however,  by  reason  of  the  virulence  of  the  infection 
it  may  spread  to  adjacent  tissues.     This  also  occurs  even  with 


236  OPERATING    EOOM    AND    THE    PATIENT 

germs  of  low  infective  power  if  drainage  is  interfered  with. 
Phlegmons  differ  clinically  according  to  the  location  of  the 
infection. 

The  infection  spreads  in  the  direction  of  least  resistance,  as, 
for  instance,  in  moderately  loose  connective  tissue,  or  along 
connective  tissue  and  intermuscular  planes,  or  along  tendon- 
sheaths.  Where  the  anatomic  peculiarities  of  the  part  present 
a  barrier  to  the  progress  of  the  infection  along  the  lines  by  which 
it  has  started  the  infection  follows  the  line  of  least  resistance 
until  another  plane  of  tissue  is  found.  Obstructing  bands  of 
tissue  have  their  blood  supply  interfered  with  bj^  pressure  of  the 
inflammatory  products  and  finally  undergo  necrosis.  This  is 
particularly  true  of  fascia  and  tendon-sheaths.  In  subcutane- 
ous jMegmon  the  skin  is  finally  attacked,  becomes  reddened, 
stretched  out,  and  perforation  occurs.  Where  the  phlegmon  is 
restricted  to  the  subcutaneous  tissue  the  elasticity  of  the  skin 
prevents  any  great  degree  of  tension  until  nature  has  set  a  firm 
barrier  of  inflammatory  tissue  around  the  original  focus  of  in- 
fection, thus  preventing  its  spread.  Usually  the  phlegmon 
becomes  circumscribed  early  and  readil}'  subsides  following 
incision. 

Intermuscular  Phlegmon. — This  may  follow  rupture  of  the 
urethra,  infected  compound  fractures,  or  infected  wounds  of  the 
neck.  The  infection  follows  the  course  of  the  deeper  fascial 
planes  and  being  beneath  them  is  not  readily  diagnosed.  This 
is  of  much  more  serious  import  than  the  subcutaneous  phlegmon, 
for  the  reason  that  the  infection  readily  travels  along  the  fascial 
planes  and  is  only  limited  by  the  boundaries  of  these  planes.  The 
general  symptoms  are  much  more  severe.  The  fever  is  higher. 
Repeated  chills,  slight  in  character,  may  precede  the  fever.  The 
rapid  pulse  and  apathetic  appearance  of  the  patient  show  the 
occurrence  of  general  infection.  The  character  of  the  pain  in 
the  affected  area  is  dull,  tense  and  not  exactly  located  by  the 
patient.  The  swelling  is  diffuse,  most  prominent  over  the  center 
of  the  infection.  An  entire  extremitj^  may  be  involved.  In  the 
case  of  the  neck,  the  infection  may  spread  to  the  opposite  side. 
The  overlying  skin  becomes  a  livid  bluish-red.  This  is  due  to 
pressure  upon  the  deep  vessels.     As  the  inflammation  approaches 


CARE    OF    THE    WOUND  237 

the  skin  more  pronounced  redness  develops.  The  overlying 
tissues  are  doughy  to  the  feel,  the  deeper  tissues  give  a  sense  of 
brawny  infiltration.  Fluctuation  is  first  felt  in  the  center  of  the 
infection.  The  center  of  the  infiltrated  mass  becomes  softened, 
and  upon  palpation  it  feels  as  if  a  hole  had  formed  in  the  center 
of  the  infiltrated  tissue.  The  function  of  the  surrounding  muscles 
is  lost  early.  The  part  is  kept  in  the  least  painful  position  and 
as  a  result  contractures  occur.  Only  rarely  does  the  phlegmon 
approach  the  surface  and  rupture  spontaneously.  If  early  inci- 
sions are  not  made  general  infection  occurs.  Incisions  must  be 
made  early  to  prevent  widespread  functional  impairment  of  the 
part. 

Tendinous  Phlegmon. — ^This  occurs  most  frequently  in  the  fore- 
arm and  hand.  It  may  follow  the  inadequate  incision  of  a  felon. 
The  phlegmon  is  initiated  by  fever  and  throbbing  pain.  Pain  is 
sufficiently  intense  to  cause  sleeplessness.  The  swelling  is  ex- 
quisitely tender.  On  account  of  the  density  of  the  palmar 
fascia  swelling  may  not  be  so  prominent  in  the  palm,  but  through 
the  pressure  of  the  secretions  under  tension  will  cause  swelling 
on  the  back  of  the  hand.  Unless  relieved  by  incision  the  tend- 
ency is  to  spread  beneath  the  carpal  ligaments  to  the  tendon- 
sheaths  of  the  forearm.  When  the  tendon-sheaths  of  the  fore- 
arm are  attacked  the  whole  forearm  becomes  swollen.  Redness 
appears  over  the  infected  tendon-sheaths.  These  rupture  and  an 
intermuscular  phlegmon  is  added.  Such  cases  should  be  incised 
at  the  earliest  possible  moment,  otherwise  the  tendon  itself  will 
surely  be  destroyed.  Incisions  must  be  free.  In  all  three  varie- 
ties of  phlegmon  early  and  free  incision  is  the  only  rational 
treatment.  Small  incisions  are  of  no  avail.  The  treatment  by 
parenchymatous  injections  of  carbolic  acid,  the  application  of 
ice,  and  the  inunction  of  ointments,  is  only  mentioned  to  be 
condemned. 

In  the  treatment  of  diffuse  cellular  infiltration,  as,  for  instance, 
the  cellular  infiltration  remaining  after  free  evacuation  of  the 
primary  focus  of  infection  in  the  case  of  a  palmar  abscess,  Bier's 
treatment  by  hyperemia  is  indicated.  This  may  be  accom- 
plished by  the  application  of  a  broad  band  of  elastic  in  the 
course  of  the  forearm  and  the  Bier  suction  apparatus  should  be 


238  OPERATING  ROOM  AND  THE  PATIENT  . 

used  in  addition.  This  treatment  is  of  decided  benefit  in  such 
diffuse  infiltrations.  It  is  only  to  be  used,  however,  after  ade- 
quate drainage  has  been  provided. 

Infection  in  Loose  Cellular  Tissues. — ^In  loose  cellular  tissues 
infection  spreads  rapidly,  as  is  the  case  in  infection  following 
operations  involving  the  scrotum.  The  infection  is  usually  of  a 
mild  character  and  rapidly  subsides  upon  the  provision  of 
efficient  drainage.  The  lower  limit  of  the  infection  should  be  in- 
cised and  a  tube  introduced  to  drain  the  infected  cellular  tissue. 
The  position  of  the'  infected  part  should  always  be  such  as  to 
favor  drainage  by  gravity;  and  counter  openings  should  be 
planned  accordingly.  Infection  in  cellular  tissue  underlying 
mucous  membrane  is  treated  by  multiple  punctures  and  scarifi- 
cations with  the  application  of  evaporating  lotions. 

Aseptic  Wounds  in  Infected  Tissues. — ^A  wound  made  in  in- 
fected tissues  is  necessarily  infected,  and  this  infection  must  be 
disposed  of  before  healing  can  occur. 

The  principles  upon  which  the  treatment  of  such  a  wound  rests 
are  adequate  drainage  and  the  hastening  of  the  separation  of 
the  sloughing  tissues.  Such  wounds  are  exemplified  by  fur- 
uncle, paronchyia  and  carbuncle.  The  wound  is  lightly  packed 
with  moist  gauze  and  kept  open.  Incisions  must  be  adequate. 
Moisture  hastens  the  separation  of  sloughs.  For  this  purpose 
alcohol-bichlorid  is  useful.  The  evaporating  qualities  of  the 
gauze  should  not  be  interfered  with.  The  dressings  should  be 
changed  sufficiently  often  to  prevent  any  stagnation  of  secretion. 
The  margins  of  the  wound  should  never  be  squeezed  in  the  en- 
deavor to  evacuate  pus  as  this  results  in  forcing  infection  into 
adjacent  tissues.  Sloughs  should  not  be  forcibly  removed. 
Those  necrotic  masses  which  come  away  easily  may  be  removed. 
Irrigating  with  saline  solution  will  wash  away  loosened  necrotic 
masses.  Peroxid  of  hydrogen  sprayed  on  the  wound  through  an 
atomizer  will  help  in  cleansing  the  wound.  These  wounds  should 
be  dressed  at  least  once  daily  until  the  slough  has  separated. 
The  parts  should  be  kept  absolutely  at  rest,  and  in  such  a  posi- 
tion as  to  provide  for  the  best  circulation.  Sprinkling  naphthalin 
crystals  over  the  wound  will  aid  in  separating  the  slough.  After 
the  wound  has  become  clean  dressings  may  be  done  every  second 


CARE    OF    THE    WOUND  239 

day.  Such  wounds  are  liable  to  be  complicated  by  lymphangitis 
and  lymphadenitis. 

Retention  of  Secretion  in  the  Wound  through  Blockage  of  the 
Drain. — There  is  slight  fever  and  general  and  local  discomfort. 
These  symptoms  may  directly  follow  the  operation,  or  supervene 
after  several  days  of  an  aseptic  course.  Upon  removal  of  the 
outer  dressing  only  a  slight  amount  of  discharge  is  found  upon  it. 
The  margins  of  the  wound  are  slightly  reddened  and  there  is 
some  pain.  The  removal  of  the  drainage  tube  or  gauze  drain  is 
followed  by  a  gush  of  pus.  The  wound  should  be  thoroughly 
cleansed  with  saline  irrigation,  and  a  drainage  strip  introduced. 
Following  this  the  discomfort  and  symptoms  of  general  infection 
disappear  and  the  parts  become  normal  in  appearance.  In  any 
case  in  which  drainage  has  been  used  the  occurrence  of  fever 
should  be  looked  upon  as  an  indication  for  the  removal  of  the 
drain  to  ascertain  whether  it  has  become  blocked.  In  the  case 
of  tube  drainage  this  is  accomplished  by  inserting  a  smaller  tube 
in  the  one  to  be  removed  and  holding  it  there  while  removing  the 
larger  one.  The  symptoms  may  continue  after  the  drain  has  been 
removed,  the  wound  cleansed  and  a  new  drain  introduced.  This 
indicates  a  focus  of  infection  which  is  not  reached  by  the  drainage. 
The  drainage  tract  must  be  explored  and  the  focus  of  infection 
found  and  efficiently  drained.  If  this  cannot  be  done  through  the 
original  drainage  opening,  a  counter-opening  must  be  provided. 

Removal  of  Gauze  Drains. — ^These  are  moistened  just  before 
removal  to  render  their  removal  less  painful  and  to  cause  less 
traumatism.  Half-strength  hydrogen  peroxid  is  useful  for 
this  purpose. 

Irrigation  of  Cavities. — In  irrigating  cavities  great  care  should 
be  taken  particularly  if  the  cavity  is  in  relation  with  the  perito- 
neum, that  fluid  is  not  forcibly  injected  into  the  wound  cavity 
with  consequent  forcing  of  infection  into  neighboring  tissues.  A 
free  exit  must  always  be  provided.  Especial  care  must  be  taken 
when  using  hydrogen  peroxid. 

Disturbances  of  Granulation. — ^The  granulating  process  may 
proceed  too  slowly  (sluggish  granulation),  too  rapidly  (exuberant 
granulation) ,  or  the  surface  of  the  wound  may  be  covered  with  a 
tough  gray  elastic   membrane    (pyogenic   membrane).     In  the 


240  OPERATING    ROOM    AND    THE    PATIENT 

wound  in  which  the  granulating  jyrocess  is  sluggish,  the  individual 
granulations  will  be  small  and  rounded,  with  spaces  between 
them.  The  granulations  do  not  grow  freely  enough;  they  lose 
their  red  color  and  become  grayish  and  shrunken.  These  slug- 
gish granulations  are  quite  apt  to  develop  in  old  people  or  in 
patients  with  lowered  vitality.  The  wound  surfaces  will  either 
be  quite  dry  or  dotted  here  and  there  with  tenacious  secretion. 
The  treatment  consists  in  exciting  granulation  by  sprinkling  the 
surface  with  naphthalin  crystals  or  with  balsam  of  Peru.  In  a 
very  sluggish  wound  the  naphthalin  crystals  are  first  used  with 
balsam  of  Peru;  later,  when  granulations  become  more  profuse, 
the  balsam  alone  may  be  used,  and  finally,  when  an  even  surface 
results,  oiled  gauze.  Curetting  the  wound  stimulates  granulation. 
Criss-cross  incisions  may  be  made  through  the  floor  of  the 
wound  and  including  the  edges  one-eighth  of  an  inch  apart  and 
deep  enough  to  reach  healthy  tissue.  Through  these  incisions 
healthy  granulations  spring. 

The  wound,  the  site  of  exuberant  granulations,  presents  a  soft, 
mushy  appearance  and  bleeds  easily.  The  granulations  fill  the 
wound.  There  is  profuse  thin  discharge.  The  cause  may  be  a 
foreign  body,  such  as  a  small  piece  of  bone  or  ligature,  or  may  be 
due  to  irritation  from  the  shifting  of  the  dressing  or  inefficient 
asepsis. 

The  treatment  is  to  remove  the  granulations  with  scissors,  to 
scrape  the  wound  with  a  curette,  and  to  paint  the  wound  with 
either  50  per  cent,  nitrate  of  silver  or  equal  parts  of  carbolic 
acid  and  iodin.  If  the  ivound  is  covered  by  a  tough  membrane, 
this  should  be  dissected  away  and  the  wound  painted  with  a 
10  per  cent,  solution  of  chlorid  of  zinc.  Following  this,  the 
wound  is  stimulated  dail}'  with  naphthalin  crystals  and  balsam 
of  Peru.  It  may  be  necessary  to  use  criss-cross  incisions  and 
to  apply  moist  dressings  to  favor  health}^  granulation.  This 
condition  occurs  most  frequently  in  neglected  wounds,  such  as 
old  ulcers.  Supporting  the  tissues  in  the  neighborhood  of  the 
wound  by  adhesive-plaster  strapping  improves  the  blood  supply. 
Scarlet  red  in  5  per  cent,  ointment  increases  the  rapidity  of 
epithelization  over  such  surfaces. 

Indolent  wounds  of  all  varieties  are  best  treated  by  scrupulous 


CARE    OF    THE    WOUND  241 

cleanliness  and  exposure  to  direct  sunlight  for  a  few  hours  daily. 
Two  layers  of  thin  gauze  serve  to  protect  the  wound  from 
dust  while  exposed  to  the  sunlight. 

Treatment  of  Varicose  Ulcers  consists  (1)  in  correcting  as 
far  as  possible  the  disturbed  conditions  of  the  circulation  on 
which  the  ulcer  depends;  (2)  in  affording  even  and  firm  support 
to  the  vessels  of  the  part,  in  order  to  minimize  as  much  as 
possible  the  tendency  to  stasis.  Elevation  of  the  limb,  with  the 
patient  in  the  horizontal  position,  whenever  this  is  possible,  is  of 
material  service  in  fulfiling  the  first  indication,  and  systematic 
strapping  and  bandaging  fulfil  the  second.  In  carrying  out  the 
latter,  all  antiseptic  conditions  should  be  complied  with.  Thor- 
ough shaving  and  scrubbing  of  the  neighborhood,  and  irrigating 
with  sublimate  solution,  should  precede  the  application  of  the 
strapping.  In  case  a  hard  elevated  ridge  circumscribes  the 
ulcer,  or  a  dense  fibrous  floor  exists,  it  will  be  necessary  first  to 
incise  these  thoroughly  in  order  that  the  vessels  beyond  and 
beneath  the  area  of  the  ulcer  may  be  permitted  to  find  their  way 
into  the  latter  and  convey  suitable  nourishing  material  for  the 
purpose  of  repair  (L.  A.  Sayre).  These  incisions  should  be  made 
about  a  quarter  of  an  inch  apart,  in  the  direction  of  the  long  axis 
of  the  limb,  and  should  penetrate  well  through  the  hard  fibrous 
floor  above  mentioned.  An  anesthetic  is  not  necessary,  under 
ordinary  circumstances,  as  the  incisions  can  be  rapidly  made, 
and  the  parts,  as  a  rule,  are  not  very  sensitive.  Bleeding 
having  ceased,  whatever  blood  remains  on  the  surrounding 
skin  should  be  carefully  wiped  away  by  means  of  a  bit  of  dry 
sterilized  gauze,  while  any  clots  which  cling  to  the  edges  of  the 
incision  or  remain  on  the  ulcerated  surface  should  be  left  undis- 
turbed. These  blood-clots  vnll  form  an  arbor  or  trellis-work, 
through  the  medium  of  which  the  surrounding  and  underlying 
vessels,  which  now  have  access  from  the  cut  edges  of  the  incisions, 
will  penetrate  and  form  new  granulation  material.  The  cir- 
culation in  the  foot  should  be  supported  by  either  a  snug  flannel 
bandage  or  circular  strips  of  adhesive  plaster,  systematically 
applied.  These  may  reach  to  within  about  two  inches  of  the 
edge  of  the  ulcer.  The  ulcer  itself  is  to  be  strapped  in  so-called 
"basket   strapping."     This   consists   of   strips   of   diachylon   or 

16 


242 


OPERATING    ROOM    AND    THE    PATIENT 


resin  plaster,  cut  in  lengths  about  one  inch  less  than  will  be 
sufficient  to  encompass  the  limb  and  not  more  than  one  inch 
wide.  When  practicable,  it  is  better  to  cut  the  strips  crosswise 
to  the  piece  as  it  is  furnished  by  the  manufacturer.  This 
facilitates  their  smooth  application.  Each  strip,  at  the  moment 
of  application,  is  heated  over  the  alcohol  lamp.  This  sterilizes 
the  surface  which  is  to  be  applied  to  the  ulcer,  and  at  the  same 
time  increases  its  adhesiveness.  The  first  strip  is  applied 
horizontally,  and  just  overlaps  the  upper  boundary  of  the  flannel 


Fig.  153. — Basket  strapping  for  ulcer  of  the  leg.  A,  Bandage  applied  to 
foot  and  ankle;  B,  basket  strapping;  C,  portion  of  ulcer  remaining  uncovered; 
D,  incisions  through  base  and  edges  of  ulcer.      (Fowler's  Surgery.) 

bandage;  it  encircles  the  limb.  The  next  strip  is  placed  verti- 
cally, or  at  right  angles  to  the  above,  and  is  likewise  placed  at 
least  two  inches  from  the  nearest  border  of  the  ulcer.  The  next 
strip  is  placed  horizontally,  and  half  overlaps  the  first.  The 
next  or  fourth  strip  is  placed  vertically  and  half  overlaps  the 
second,  or  the  vertical  strip  which  has  preceded  it.  The  process 
is  now  continued  in  the  same  manner,  alternate  horizontal  and 
vertical  strips  being  applied  until  the  entire  surface  of  the  ulcer 


CARE    OF    THE    WOUND  243 

is  gradually  covered  (Fig.  153).  The  strapping  is  carried  well 
above  and  beyond  the  margins  of  the  ulcer.  An  antiseptic 
compress,  made  of  crumpled  gauze  and  large  enough  to  cover 
and  overlap  the  plaster  strapping,  is  now  placed  over  the  latter, 
and  over  all,  including  the  flannel  bandage  of  the  foot,  a  roller 
bandage  is  firmly  applied.  Should  no  discharge  or  other 
evidences  of  disturbance  occur,  the  dressings  should  be  allowed 
to  remain  for  from  ten  to  fourteen  days;  the  patient,  as  a  rule,  is 
permitted  to  walk  about.  At  the  end  of  this  time  the  bandage 
and  plaster  are  to  be  slit  up  with  a  pair  of  bandage  scissors,  care 
being  taken  in  doing  this  to  select  a  point  sufficiently  far  from 
the  site  of  the  ulcer  in  order  to  avoid  injuring  this  with  the 
scissors.  The  bandages  and  plaster  are  now  removed,  the 
latter  peeling  off  like  the  bark  of  a  tree.  Some  tenacious 
secretion  from  the  ulcerated  surface  will  be  found  on  the  plaster, 
as  well  as  on  the  neighboring  skin.  From  the  latter  situation 
it  may  be  removed  with  a  piece  of  sterilized  gauze;  on  no  account 
should  the  gauze  be  permitted  to  come  in  contact  with  the 
ulcer  itself.  In  lieu  thereof  a  gentle  stream  of  a  mild  antiseptic 
solution  (boric  acid  1:1000)  should  be  allowed  to  flow  over  the 
surface  of  the  ulcer  until  it  is  thoroughly  cleansed.  A  striking 
change  will  be  found  to  have  taken  place  in  the  ulcer.  In 
place  of  the  hard  and  elevated  edge,  which  will  be  found  to 
have  disappeared,  there  is  a  soft  flattened  margin,  from  which  a 
white  or  pale  blue  line  of  new  epidermis  is  already  forming. 
The  hard  and  smooth  floor  will  have  given  place  to  a  bed  of 
soft  and  healthy  granulations.  The  incisions,  where  they  cross 
the  margins,  gape  widely  and  are  filled  with  healthy  granulations. 
The  antiseptic  solution  is  not  to  be  dried  from  the  surface  of  the 
granulations;  only  the  surrounding  skin  is  to  be  dried.  Precisely 
the  same  course  is  now  followed   as   at  first. 

It  may  happen  that  the  first  dressings  will  need  replacing 
before  the  time  specified  above,  owing  to  the  occurrence  of  dis- 
charge through  the  bandage;  it  is  rare,  however,  that  a  bandage 
cannot  remain  on  at  least  a  week.  Two  or  three-  dressings, 
except  in  exceptionally  large  ulcers,  usually  suffice,  when  the 
epidermal  layer  is  found  to  have  completely  covered  the  granu- 
lating surface,  and  the  cure  is  complete.     The  patient  should 


244 


OPERATIXG    ROOM    AXD    THE    PATIENT 


thereafter,  in  order  to  escape  relapse,  wear  a  silk  elastic  stocking 
to  support  the  circulation  in  the  part,  care  being  taken  in  the 
beginning  to  place  a  piece  of  soft  linen  or  lint  over  the  newly- 
formed  cicatrix  in  order  that  this  may  not  become  irritated  and 
renewed  ulceration  occur.  In  case  of  the  latter  the  skin-grafting 
method  of  Reverdin  oi  that  of  Thiersch  shoiild  be  employed. 
Although  chronic  ulcers  of  the  extremity  are  far  more  amenable 
to  treatment  now  than  formerly,  there  are  still  cases  w^hich  are 
intractable,  suggesting  malignant  disease.  Still  others  extend 
deeply  and  involve  the  periosteum,  necrosis  resulting.  In  these 
cases,  as  well  as  in  some  instances  which  involve 
the  entire  circumference  of  the  leg  (circular  ulcer), 
other  measures  failing,  the  resort  to  amputation  is 
justifiable. 

Sinus. — ^It  sometimes  happens  that  following  an 
infection  the  wound  heals  until  only  a  small  sinus 
is  left.  This  may  prove  persistent.  In  treating  a 
sinus  a  thorough  exploration  of  it  must  first  be 
made  with  a  slender  probe.  The  depth  and  direction 
of  the  sinus  is  noted,  and  also  its  width.  It  may 
be  found  to  communicate  with  a  cavity  deep  in  the 
wound,  or  it  may  be  found  to  widen  put  in  its 
depths.  In  either  of  these  events  the  external  open- 
ing must  be  enlarged  to  correspond  in  extent  to 
the  depths  of  the  sinus.  The  entire  sinus  surface  is 
then  curetted  (Fig.  154)  and  packed  with  gauze 
saturated  with  balsam  of  Peru.  This  dressing  should 
be  renewed  daily.  In  case  of  a  simple  sinus  with 
no  enlargement  toward  the  bottom  of  the  sinus 
repeated  curetting  will  usually  effect  a  cure.  In 
ver}'  small  sinuses  a  curettement  followed  by  the 
injection  of  a  few  minims'  of  95  per  cent,  carbolic 
acid,  or  of  a  few  minims  of  ecpal  parts  of  carbolic  acid  and 
iodin,  will  usually  serve  to  effect  a  cure.  This  is  best  done 
by  means  of  a  sinus  syringe  (Fig.  155).  After  allowing  the 
carbolic  acid  to  remain  in  the  sinus  for  two  minutes,  the 
sinus  is  syringed  out  with  pure  alcohol.  Sinuses  treated  in 
this  way  do  not  require  drainage  except  possibly  to  keep  the 


Fig.  154. 
Delatour's 
sinus  curette. 
(Fowler's 
Surgery.) 


CARE    OF    THE    WOUND 


245 


if\l 


111 


external  skin  opening  patent,  in  which  event  a  short  rubber  tube 
is  placed  in  the  skin  opening  and  kept  from  entering  the  depths 
of  the  sinus  by  means  of  a  safety-pin. 

In  sinuses  which  have  been  in  existence  for  a  considerable 
time  and  in  which  the  walls  are  hard  and  tough, 
the  sinus  is  curetted  and  chlorid  of  zinc  applied 
by  means  of  an  applicator.  If  a  few  treatments 
of  this  kind  do  not  suffice  for  a  cure,  it  will  be 
necessary  to  dissect  the  sinus  out  in  its  entirety. 

Occasionally  the  cause  of  a  persistent  sinus  will 
be  found  to  be  an  unabsorbed  ligature  or  piece 
of  suture  material.  The  curette  is  usually  not 
sufficient  to  engage  the  small  piece  of  catgut  or 
silkworm  gut  lying  at  the  bottom  of  the  sinus; 
to  remove  this,  several  loops  of  silkworm  gut  are 
fastened  by  silk  to  the  flat  end  of  a  slender  probe. 
This  little  apparatus  is  carefully  introduced  to  the 
bottom  of  the  sinus  when  the  probe  is  twirled  be- 
tween the  fingers  so  that  the  offending  material  is 
immeshed  in  the  loops  of  silkworm  gut  and  so  re- 
moved. Persistent  sinuses  may  be  the  result  of 
tuberculous  infection. 

Thermocautery  Wounds. — ^If  the  operation  was 
done  with  a  thermocautery,  as  in  the  treatment  of 
lupus,  gangrene,  anthrax,  and  some  forms  of  nevi, 
the  resulting  wound  should  be  dressed  for  the  first 
few  times  with  boracic  acid  ointment.  The  eschar 
resulting  from  the  use  of  the  cautery  separates  in 
from  eight  to  ten  days,  leaving  an  underlying 
healthy  granulating  surface  which  may  be  skin 
grafted,  or  the  ointment  dressings  may  be  con- 
tinued if  the  area  is  small.  Scarring  following  the 
use  of  the  thermocautery  is  remarkably  slight  where  the  entire 
thickness  of  the  skin  has  been  destroyed. 

Care  of  the  Skin  in  the  Neighborhood  of  the  Wound.— Wounds 
healing  per  primam  are  left  alone.  In  wounds  healing  by 
granulation  in  which  the  process  is  not  rapid  great  benefit  is 
derived   by   gently  massaging  the  skin  near  the  wound.     The 


Fig.  155. 

Sinus  syringe. 

(Fowler's 

Surgery.) 


246  OPERATING    ROOM    AND    THE    PATIENT 

hyperemia  produced  results  in  the  more  rapid  formation  of  new 
blood  vessels.  In  all  open  wounds  the  skin  in  the  neighborhood 
should  be  gently  cleansed  at  each  dressing  both  for  the  reason 
just  given  and  to  prevent  dermatitis  from  irritation  from  the 
discharge. 

Vaccine  Therapy  of  Infection. — ^Immediately  upon  the  appear- 
ance of  infection  a  culture  should  be  taken  from  the  wound  and 
a  vaccine  prepared  for  possible  use.  If  alarming  symptoms 
become  manifest  pending  the  manufacture  of  the  autogenous 
vaccine  a  stock  polyvalent  vaccine  should  be  given.  Rarely 
under  proper  surgical  care  will  it  be  necessary  to  use  either  stock 
or  autogenous  vaccine  but  should  the  emergency  arise  it  is  very 
comforting  to  the  surgeon  to  have  the  autogenous  vaccine  ready. 
It  must  be  remembered  that  vaccines  are  adjuncts  to  surgical 
treatment  and  not  to  be  alone  relied  upon.  They  must  be  com- 
bined with  the  established  methods  of  wound  treatment.  Al- 
though preliminary  work  had  previously  been  done  by  others, 
the  credit  of  establishing  vaccine  therapy  on  its  present  basis 
must  be  awarded  almost  entirely  to  Dr.  A.  E.  Wright.  Metsch- 
nikoff's  work  on  phagoc}'tosis  is  too  well  known  to  require  more 
than  mention.  Wright  went  one  step  further  by  demonstrating 
that  before  phagocytosis  could  take  place  a  substance  must  be 
present  which  acts  on  the  bacteria  and  prepares  them  for  inges- 
tion by  the  phagocytes.  These  substances,  apparently  specific 
for  each  species  of  bacteria,  he  calls  "opsonins."  The  amount 
of  these  opsonins  in  any  given  case  he  measures  by  ascertaining 
by  appropriate  means  the  phagocytic  capacity  of  the  individual 
to  be  tested  toward  a  specific  organism  and  comparing  it  with  the 
phagocytic  capacity  of  a  "pool"  of  blood  taken  from  several 
normal  persons  and  mixed.  This  comparison  gives  what  he  calls 
the  "opsonic  index." 

Wright  further  showed  that  the  opsonin  content  of  the  blood 
could  be  increased  by  the  subcutaneous  injection  of  bacteria 
killed  by  heat. 

On  this  basis,  "Vaccine  Therapy"  consists  in  the  attempt  to 
produce  an  active  immunity  by  the  injection  into  the  tissues  of 
dead  bacteria,  thus  increasing  the  opsonins;  or  in  more  general 
terms,  stimulating  the  production  of  specific  antibodies. 


CARE    OF    THE    WOUND  247 

In  the  beginning  this  method  of  treatment  was  used  only  in 
connection  with  the  opsonic  index.  The  index  was  taken  before 
and  after  the  injection,  and  repeated  at  intervals.  A  second 
dose  was  administered  only  when  the  opsonic  index  was  believed 
to  have  reached  its  highest  point  or  begun  to  decline.  It  was 
found  that  the  first  effect  of  the  treatment  was  to  cause  a  lowering 
of  the  opsonins,  to  cope  with  the  bacteria  and  toxins  injected, 
and  this  has  been  called  the  '^ negative  phase"  and  corresponds 
to  a  period  of  lessened  resistance.  This  lasts  about  twenty-four 
hours  and  is  followed  by  a  gradual  rise  to  and  above  normal,  the 
so-called  "positive  phase,"  after  which  the  opsonins  begin  to 
decline  again.  This  period  with  moderate  doses  lasts  eight  or 
ten  days.  It  is  the  aim  of  treatment  to  repeat  the  dose  at  the 
top  of  each  successively  increasing  wave  of  the  positive  phase, 
thus  producing  a  steadily  increasing  immunity. 

Later  experience  has  demonstrated  that  to  a  large  extent  this 
mode  of  treatment  may  be  carried  out  depending  on  the  clinical 
symptoms  as  a  guide  to  dosage  and  intervals,  thus  doing  away 
with  the  tedious,  difficult,  time  consuming  and  necessarily  ex- 
pensive "opsonic  index"  and  thus  greatly  extending  the  possi- 
bility of  the  treatment. 

It  is  perhaps  too  early  to  speak  dogmatically  as  to  the  value 
of  this  mode  of  treatment,  but  increasing  experience  seems  to 
demonstrate  more  and  more  its  safety  and  efficiency.  Given 
a  proper  dose,  at  suitable  intervals,  in  proper  cases,  bacterial 
vaccines  may  be  said  to  be  perfectly  safe.  Wrongly  given  they 
are  capable  of  doing  much  damage,  but  the  same  is  true  of  any 
powerful  therapeutic  agent. 

To  produce  such  vaccines,  the  specific  organisms  are  cultivated 
in  the  incubator  for  twenty-four  hours  on  the  surface  of  a  solid 
medium  such  as  bouillon  agar  or  other  medium,  depending  on  the 
requirements  of  the  specific  organism.  A  little  sterile  saline  so- 
lution is  then  poured  over  the  growth,  which  is  gently  scraped 
off  with  a  sterile  platinum  needle. 

The  resulting  emulsion  is  then  well  shaken  in  a  tube  with  a 
few  glass  beads  to  break  up  the  clumps,  and  the  resulting  vaccine 
is  standardized  as  follows:  In  a  capillary  pipette,  one  volume 
of  vaccine  emulsion,  one  of  blood,  of  normal  standard  (5,000,000 


248  OPERATING    ROOM    AND    THE    PATIENT 

red  cells  per  cm.)  and  three  volumes  of  2  per  cent,  sodium  citrate 
solution  to  prevent  clotting,  are  thoroughly  mixed  and  one  drop 
spread  on  a  slide  and  stained,  as  for  blood  counting.  With  a 
crossline  eye  piece  micrometer  the  number  of  red  cells  and  also 
of  bacteria  in  a  number  of  fields  are  counted,  and  the  number  of 
bacteria  in  1  cm,  of  the  emulsion  calculated.  This  is  then 
diluted  to  a  suitable  strength  with  sterile  normal  saline  solution. 
The  next  stage  consists  in  killing  the  bacteria  by  heating  to  a  suit- 
able temperature  for  one  hour  on  three  successive  days.  In  the  case 
of  the  pyogenic  cocci,  60°  C.  is  found  to  work  well.  After  steriliz- 
ing, the  product  is  tested  by  culture  to  prove  that  it  is  sterile,  and 
is  then  ready  for  use.  An  autogenous  vaccine  requires  four  or 
five  days  or  more  to  make,  so  a  stock  vaccine  may  be  used  in  the 
interval.  In  some  cases,  e.g.,  gonorrheal  infections,  outside  of 
the  urinary  tract,  stock  vaccines  are  said  to  act  as  well  as  autog- 
enous. Pyogenic  infections,  and  those  with  colon  bacilli  do 
better  if  treated  with  autogenous  vaccines.  If  stock  vaccines 
are  used  those  are  best  if  "polyvalent" — i.e.,  made  from  several 
different  strains  of  the  same  organism  from  diverse  sources. 
Combined  vaccines  are  made  of  a  mixture  of  several  different 
.organisms — e.g.,  colon  bacilli,  streptococcus,  staphylococcus — 
and  may  be  used  in  mixed  infections  or  in  emergency  when  the 
infecting  organism  is  unknown. 

Dosage. — No  specific  rules  can  as  yet  be  laid  down.  Each 
case  must  be  judged  individually  in  accordance  with  the  symptoms 
and  the  degree  of  reaction.  The  dose  is  measured  by  the  number 
of  organisms  injected,  not  hy  the  hulk  of  the  fluid.  Ordinary 
doses  for  adults  vary  from  5,000,000  to  1,000,000,000.  Acute 
cases  call  for  small  doses  at  short  intervals — one  to  four  days.  As 
the  symptoms  improve,  larger  doses  and  longer  intervals  be- 
come the  rule.  If  the  reaction  is  very  marked,  as  shown  by 
increase  of  fever  and  other  symptoms  or  locally  by  marked  swel- 
ling, pain,  tenderness  and  redness,  this  is  an  indication  for  les- 
sening the  dose  and  increasing  the  intervals.  Large  doses,  of 
several  hundred  millions  should  not  be  repeated  oftener  than 
eight  or  ten  days  apart,  as  it  takes  that  long  for  the  opsonins  to 
reach  their  height.  The  more  virulent  bacteria  are  naturally 
given  in  smaller  doses— e.y.,  streptococci,  two  to  fifty  millions. 


CARE    OF    THE    WOUND  249 

Staphylococcus  pyogenes  and  colon  bacillus  vaccines   are  given 
in  doses  of  fifty  to  five  hundred  millions  or  sometimes  more. 

In  the  acute .  cases,  small  doses  avoid  the  production  of  a 
negative  phase,  and  the  positive  phase,  though  produced  promptly 
is  relatively  slight  and  transient. 

Staphylococcus  infections  (albus,  aureus,  citrous)  including 
boils,  felons,  carbuncles,  septic  wounds,  post-operative  sinuses, 
do  well  almost  invariably  when  treated  with  the  appropriate 
vaccine.  Failure  here  usually  indicates  either  the  selection  of  the 
wrong  vaccine  at  the  start,  or  a  subsequent  infection  with  some 
other  organism.  A  conservative  initial  dose  would  be  50  to  100 
millions,  and  if  no  marked  reaction  occurs,  this  may  be  repeated 
in  a  day  or  two.  As  the  patient  improves  the  dose  may  be  in-' 
creased  to  750  to  1000  millions  every  eight  or  ten  days. 

Streptococcus  infections  do  well  under  vaccine  treatment, 
more  particularly  the  local  forms.  The  dose  of  streptococcus 
vaccines  is  always  small  as  compared  to  most  others,  two  to  fifteen 
millions  are  all  that  should  ordinarily  be  given.  Erysipelas 
yields  well  and  certainly  to  appropriate  treatment.  The  fol- 
lowing rules  for  dosage,  according  the  Ross  are  quoted  from 
Synnott:  "Five  million  streptococci  are  given  to  a  severe  case  in 
the  first  inoculation  and  ten  if  the  case  is  less  severe.  On  the 
second  day  the  severe  case  is  given  five  million  more  if  there  be 
signs  of  improvement.  The  most  important  of  these'  latter, 
according  to  Ross,  is  a  clearing  of  the  intellect  and  less  tender- 
ness and  pain  in  the  local  condition.  There  may  be  a  moderate 
fall  in  the  temperature  on  the  morning  following  the  injection. 
A  drop  of  two  or  three  degrees  would  be  a  valuable  indication  for 
a  second  inoculation.  If  the  severe  case  shows  no  improvement 
the  second  inoculation  should  consist  of  only  two  and  a  half 
million.  In  less  severe  cases  improvement  is  almost  always 
manifested  after  twenty-four  hours  and  the  patient  receives  half 
the  first  dose  or  five  millions.  Thereafter  two  and  a  half,  five 
or  ten  million  are  given  every  second  day  until  a  week  after  the 
temperature  has  reached  normal,  and  the  erythema  has  subsided. 
The  severity  of  the  infection  must  be  our  guide  to  dosage.  The 
more  severe  the  case  and  the  less  satisfactory  the  clinical  re- 
sponse, the  smaller  the  dose." 


250  OPEEATIXG    EOOM    AXD    THE    PATIENT 

Colon  bacillus  infections  of  the  genito-urinary  tract  and 
elsewhere  may  be  treated  with  vaccines  with  benefit.  Autog- 
enous vaccines  are  necessarj^  in  these  cases,  as  the  various 
strains  of  colon  bacilli  vary  so  that  stock  vaccines  have  proved 
very  disappointing.  At  best,  treatment  with  colon  bacillus 
vaccines  is  somewhat  uncertain.  Many  cases  are  cured  promptly 
some  are  improved,  and  in  some  cases  no  amelioration  is  pro- 
duced. The  initial  dose  is  five  to  twenty  million  and  this  may 
be  continuously  increased  to  as  much  as  five  hundred  million 
every  ten  days. 

Gonococcus  vaccines  up  to  the  present  time  have  been 
disappointing  in  acute  urethritis,  but  constitute  a  valuable 
therapeutic  measure  in  gonorrheal  rheumatism  and  some  cases 
of  chronic  gonorrheal  urethritis.  Stock  poh"\'alent  vaccines 
give  as  good  results  as  autogenous  vaccines.  Dose,  one  to  fifty 
million. 

The  pneumococcus  is  sometimes  responsible  for  surgical 
lesions,  such  as  empyema  and  otitis  media.  The  appropriate 
A'accine  is  indicated,  initial  dose,  fifteen  to  twenty  million. 

Antitoxins. — ^In  the  case  of  three  diseases  only  has  the  use  of  an 
antitoxin  (serum)  been  followed  by  dependable  results:  viz., 
diphtheria,  tetanus,  and  epidemic  cerebrospinal  meningitis. 
Diphtheria  will  not  be  here  considered  as  not  being  ordinarily  a 
surgical  disease. 

In  tetanus  the  results  are  not  so  uniformly  gratifj-ing  as  in 
diphtheria,  but  the  method  is  of  great  value.  Large  doses  of  the 
serum  are  indicated  in  the  presence  of  the  disease  up  to  as  much  as 
fifty  thousand  units  several  times  a  day  until  amelioration  sets 
in.  The  value  of  tetanus  antitoxin  as  a  prophylactic  in  suspected 
wounds  is  certain.  Fifteen  hundred  units  as  early  as  possible 
after  the  injury  repeated  in  ten  days  is  the  usual  dose. 

Antimeningitis  serum,  introduced  by  Flexner  has  sho-^m  bril- 
liant results  in  the  treatment  of  meningitis  due  to  the  meningo- 
coccus. The  spinal  canal  is  punctured  under  aseptic  precautions 
in  the  usual  manner  and  a  quantity  of  the  subdural  fluid  at  least 
equal  in  quantity  to  the  volume  of  serum  to  be  injected,  is  first 
drawn  off,  the  s^Tinge  then  attached  and  the  serum  injected 
directly   into   the   subdural   space.     Subcutaneous   injection   is 


CARE    OF    THE    WOUND  251 

useless,  as  the  serum  must  come  in  direct  contact  with  the  cocci 
localized  in  the  spinal  canal. 

Bier's  Hyperemia. — The  aim  of  Bier's  hyperemic  treatment 
is  to  increase  the  usual  inflammatory  hyperemia  brought  about 
by  nature  in  its  fight  against  the  disease  present,  and  where  it  is 
lacking  to  stimulate  it.  Whatever  method  be  used  to  produce 
or  increase  hyperemia  the  blood  must  continue  to  circulate  and 
there  must  never  be  a  stasis  of  the  blood. 

Advantages. — The  advantages  claimed  for  the  treatment 
are  the  suppression  of  infection,  the  avoidance  of  suppuration  in 
many  cases,  the  possibility  of  using  a  small  instead  of  a  large 
incision  in  cases  where  suppuration  has  already  set  in,  the  hasten- 
ing of  the  course  of  the  pathologic  processes,  the  favoring  of 
absorption,  the  diminution  of  pain  and  the  wide  field  of  its 
application. 

Passive  or  venous  hyperemia  may  be  induced  by  means  of 
an  elastic  bandage  or  band,  or  by  means  of  cupping  glasses  of 
various  size  and  shape.  Active  or  arterial  hyperemia  may  be 
induced  by  means  of  hot  air. 

Bier's  Hyperemia  by  Means  of  an  Elastic  Bandage. — The 
hyperemia  of  parts  other  than  those  diseased  is  not  deleterious. 
An  elastic  band  or  bandage  according  to  the  configuration  of  the 
parts  is  applied  at  the  most  convenient  healthy  place  between 
the  area  of  inflammation  and  the  heart,  firmly  enough  to  slightly 
constrict  the  veins  but  not  so  firmly  as  to  compress  the  arteries. 
This  latter  is  determined  by  palpating  the  pulse  below  the 
bandage.  The  tendency  is  to  apply  the  bandage  too  tightly, 
therefore  it  must  be  emphasized  that  Bier's  hyperemia  is  not  a 
stasis  hyperemia. 

Feelings  of  the  Patient. — If  any  complaint  of  pain  or  a  sense 
of  constriction  or  paresthesias  are  noted,  the  bandage  has  been 
too  tightly  applied.  Too  tight  application  of  the  bandage 
results  in  too  rapid  turgescence  of  the  subcutaneous  veins. 
The  extremity  assumes  a  bluish-red  appearance,  and  later  red 
blotches  and  small  cutaneous  hemorrhages  occur,  while  later 
still  cyanosis  becomes  extreme  and  the  pulse  disappears  if  the 
constricting  band  is  not  loosened.  There  should  be  absolutely 
no  increase  in  pain.     Less  frequently  the  bandage  is  applied  too 


252  OPERATING    ROOM    AXD    THE    PATIENT 

loosely  resulting  in  a  slight   obstruction  to  the  return  of  the 
h'mph  but  producing  no  venous  congestion  whatever. 

The  band  or  bandage  employed  varies  with  the  part  to  which 
it  is  to  be  applied.  If  applied  along  the  course  of  an  extremity : 
a  soft  rubber  bandage  two  and  one-half  inches  wide  and  of  a 
length  sufficient  to  surround  the  limb  six  or  eight  times  is  used. 
In  applying  the  bandage  one  layer  overlaps  the  other  by  about 
one-half  inch  so  that  pressure  is  distributed  over  a  comparatively 
wide  area.  The  bandage  may  be  secured  by  a  strip  of  adhesive 
plaster,  by  pinning  or  by  tying  it  with  tapes  sewn  to  the  bandage. 
If  there  is  a  tendency  for  the  bandage  to  slip  more  turns  may  be 
used  or  the  bandage  may  be  additionally  secured  with  adhesive 
plaster  strips.  Where  the  bandage  is  to  remain  for  long  periods 
or  in  persons  with  tender  skin,  a  flannel  bandage  is  applied 
beneath  the  rubber  bandage.  It  is  not  necessary  to  always 
reapply  the  bandage  in  exactly  the  same  place.  A  slight  change 
in  position  at  each  reapplication  will  obviate  skin  disturbances. 
In  affections  of  the  upper  and  lower  extremities  the  bandage  is 
placed  around  the  arm  or  thigh  as  here  the  entire  venous  return 
is  under  control  of  the  bandage.  For  producing  hyperemia  by 
band  in  the  neighborhood  of  the  shoulder-joint  a  rubber  tube  is 
fastened  with  a  tape  or  clamp  snugly  about  the  shoulder.  This 
is  held  in  place  and  its  tension  increased  by  a  broad  bandage 
passed  through  it  and  around  the  neck.  A  piece  of  bandage  is 
fastened  to  the  tubing  in  front  and  behind,  the  ends  being  tied 
in  the  axilla  of  the  opposite  side.  Hyperemia  b}^  constricting 
band  is  not  possible  in  the  neighborhood  of  the  hip-joint.  Arte- 
rial hyperemia  can  be  produced  but  not  venous. 

In  producing  hyperemia  of  the  head  a  strip  of  elastic  webbing 
three  or  four  inches  wide  with  a  hook  at  one  end  an(i  a  number 
of  eyes  on  the  other  is  used.  The  band  is  applied  about  the  neck 
below  the  larynx;  on  either  side  a  piece  of  soft  material  such  as 
felt  or  lambs'  wool  is  tucked  beneath  the  bandage  over  the 
jugular  vein. 

For  producing  hyperemia  in  the  treatment  of  diseases  of  the 
testicles,  a  piece  of  rubber  tubing  of  convenient  length  and  size 
surrounds  the  root  of  the  scrotum,  the  necessary  tension  being 
secured  by  a  small  clamp  or  tape.     Skin  irritation  is  prevented 


CARE    OF    THE    WOUND  253 

by  placing  a  layer  of  soft  material  beneath  the  tubing.  The 
degree  of  hyperemia  is  judged  by  the  appearance  of  the  super- 
ficial veins. 

Care  of  the  Wound  duriyig  the  Hyperemia. — All  dressings  are 
removed  except  a  few  layers  of  gauze  loosely  held  in  place. 
The  parts  are  maintained  in  a  comfortable  position.  In  acute 
infections  the  rapid  absorption  of  the  inflammatory  edema 
accompanying  hyperemia  is  often  accompanied  by  a  temporary 
rise  in  temperature.  Hyperemia  causes  more  profuse  wound 
discharge,  hence  more  frequent  change  of  dressings  is  indicated. 
It  must  be  borne  in  mind  that  hyperemia  is  not  the  cure  of 
infection  but  is  only  an  adjunct  to  ordinary  surgical  treatment. 
It  helps  nature  abort  infections  in  the  early  stages,  causes  more 
rapid  localization  of  infection  in  the  later  stages  and  by  causing 
freer  osmosis  through  the  wound  hastens  the  separation  of 
sloughs  and  the  healing  process  generally. 

Edema  accompanying  Hyperemia. — A  certain  amount  of 
lymphatic  edema  necessarily  accompanies  hyperemia  that  is 
continued  for  several  hours.  This  edema  becomes  absorbed 
during  the  period  of  rest  between  the  applications  of  the  hypere- 
mia, unless  it  has  been  necessary  to  continue  the  hyperemia  for 
long  periods  of  time,  twenty  to  twenty-two  hours  out  of  the 
twenty-four,  in  which  case  the  absorption  of  the  edema  is  favored 
by  elevation  of  the  affected  parts  during  the  rest  period. 

Duration  of  Application  of  Hyperemia. — ^Acute  inflammatory 
processes  require  prolonged  application,  twenty  to  twenty-two 
hours  a  day.  Chronic  affections,  particularly  tuberculous 
cases,  require  two  to  four  hours  a  day. 

Hyperemia  by  Means  of  Cupping  Glasses. — ^These  cups  are  of 
various  shape  and  size  to  fit  different  parts  of  the  body.  To  the 
glass  is  attached  a  rubber  bulb  or  provision  is  made  for  attaching 
a  rubber  tube  with  a  three-way  stopcock  to  which  a  suction 
pump  may  be  attached.  Large  forms  are  made  in  which  the 
hand  and  part  of  the  forearm  may  be  placed  or  the  foot  and  part 
of  the  leg;  also  apparatus  for  the  elbow -joint  and  for  the 
knee-joint. 

Technic. — -In  using  the  smaller  cups  the  edge  of  the  cup  is 
first  smeared  with  vaselin.     With  the  rubber  bulb  collapsed,  the 


254  OPERATING  ROOM  AND  THE  PATIENT 

cup  is  applied  to  the  parts;  releasing  the  rubber  bulb  causes  a 
vacuum  within  the  cup.  The  underlying  tissues  are  sucked  up 
into  the  cup  and  this  causes  hyperemia  of  the  area  which  extends 
into  the  deeper  tissues.  Care  must  be  taken  not  to  produce  too 
much  suction.  The  skin  should  be  bluish  red,  never  white. 
With  the  larger  cups  the  vacuum  is  produced  by  means  of  a 
vacuum  pump. 

Care  of  the  Wound  during  Hyperemia  hy  Suction. — ^The  suction 
apparatus  serves  two  purposes;  it  not  only  produces  hyperemia 
in  the  parts  but  also  serves  to  cleanse  the  wound.  Wound 
discharges  are  aspirated  slowly.  Suction  may  be  sufficient  to 
drain  away  the  necrotic  tissues.  In  most  instances  packing  or 
tube  drainage  of  the  wound  treated  in  this  manner  is  not  neces- 
sary. Following  the  removal  of  the  cup  the  surroundings  of 
the  wound  are  cleansed  and  an  external  dressing  applied.  At 
the  first  application  of  the  cup  some  bleeding  may  occur;  this  as 
a  rule  does  not  continue  and  need  occasion  no  alarm. 

Duration  of  Application. — Bier's  advice  is  to  apply  the  cup 
daily  six  times  for  five  minutes  with  intervals  of  three  minutes 
between  the  applications.  The  duration  of  the  application, 
however,  will  vary  somewhat  with  individual  cases.  The  rest 
periods  are  for  the  purpose  of  allowing  the  subsidence  of  the 
accompanying  edema.  Care  in  the  application  will  prevent 
soiling  of  the  I'ubber  parts.  The  cup  and  glass  parts  are  boiled 
and  kept  sterile. 

Larger  Apparatus. — ^In  the  use  of  the  larger  apparatus  for  the 
hand,  foot,  knee,  elbow,  etc.,  the  rule  that  the  application  shall 
be  absolutely  painless  and  shall  not  interrupt  circulation  must 
be  borne  in  mind.  Such  apparatus  is  not  only  useful  in  the  treat- 
ment of  infection  but  has  given  excellent  results  in  mobilizing 
stiff  joints. 

Bismuth  Paste  (Beck).  Technic  of  the  Injection. — ^Two 
formulas  are  employed.  The  first  consisting  of  one  part  bismuth 
subnitrate,  arsenic  free,  and  two  parts  vaselin  either  yellow  or 
white,  is  employed  for  diagnostic  purposes  and  for  the  first 
treatment  injection.  Should  a  longer  retention  of  the  paste  be 
desired  the  following  formula  which  makes  a  firmer  paste  may  be 
employed: 


CARE    OF    THE    WOUND  255 

Bismuth  subnitrate 30  per  cent. 

Vaselin ■  60  per  cent. 

Paraffin  (120°  melting-point) 5  per  cent. 

White  wax 5  per  cent. 

In  preparing  formula  No.  1  the  vaselin  is  first  boiled  in  an 
enameled  jar  and  the  bismuth  powder  stirred  in  while  cooling. 
Care  should  be  taken  to  exclude  any  water  from  the  mixture  as 
this  will  destroy  its  homogeneous  consistency  and  prevent  it 
from  becoming  firm.  The  resulting  paste  is  smooth  and  yellow 
and  upon  being  heated  over  a  water  bath  becomes  sufficiently 
liquid  to  allow  its  being  drawn  into  a  glass  syringe.  Formula 
No.  2  is  prepared  in  the  same  manner,  the  paraffin  and  white 
wax  being  stirred  in  while  the  vaselin  is  still  boiling.  Various 
types  of  glass  and  metal  syringes  are  used  for  the  injection 
according  to  the  character  of  the  sinus  cavity  to  be  filled. 

On  injecting  a  sinus  the  external  opening  and  its  surroundings 
are  cleansed  with  alcohol;  there  is  no  preliminary  irrigation  or 
curettage.  With  the  tip  of  the  syringe  placed  so  as  to  fully 
occlude  the  opening  of  the  sinus  the  liquefied  paste  is  injected 
slowly  and  with  gentle  force  until  the  patient  complains  of  pres- 
sure or  there  is  such  resistance  as  to  cause  a  return  of  the  paste. 
The  syringe  is  then  removed  and  pressure  made  against  the 
external  opening  of  the  sinus  to  prevent  the  return  of  the  paste 
until  cooling  and  consequent  hardening  occurs.  All  the  ramifi- 
cations of  the  sinus  will  be  penetrated  by  the  liquefied  paste 
which,  in  the  case  of  formula  No.  1  will  remain  long  enough  to 
allow  of  radiography  of  the  injected  region.  Such  a  radiogram 
shows  a  clear  picture  of  the  sinus  and  its  ramifications  and  in 
many  instances  traces  the  sinus  to  the  original  focus  of  disease. 
Hardening  occurs  quickly  after  the  use  of  formula  No.  2.  The 
quantity  to  be  injected  varies  with  the  character  of  the  sinus. 
Except  in  sinuses  with  large  drainage  openings  it  is  not  advisable, 
however,  to  inject  more  than  100  grams. 

Contra-indications. — ^Injections  of  bismuth  paste  are  contra- 
indicated  in  acute  inflammatory  conditions.  The  Becks  have 
occasionally  noted  aggravation  of  symptoms  after  its  use  in 
acute  cases.  The  paste  should  never  be  administered  through 
a  hypodermic  needle  as  in  such  a  procedure  there  is  danger  that 


256  OPERATING    ROOM    AND    THE    PATIEXT 

some  of  the  paste  may  be  forced  into  a  vein  and  so  act  as  emboli. 
Great  care  should  be  exercised  in  injecting  the  paste  in  sinuses 
which  may  have  their  origin  in  the  cranium  as  here  there  is  a 
possibility  that  the  injected  material  may  find  its  way  into  the 
subdural  space.  An  injection  should  never  be  made  into  fistulas 
communicating  with  the  gall-bladder  or  pancreas. 

Causes  of  Failure. — Sequestra  are  the  most  frequent  causes  of 
failure.  These  can  be  recognized  by  radiography  using  formula 
Xo.  1.  Their  removal  is  indicated  before  making  an  injection 
with  formula  Xo.  2  unless  the  operation  is  one  of  magnitude,  in 
which  event  formula  Xo.  2  may  be  injected,  though  without  a 
certainty  of  cure.  The  Becks  report  two  instances  in  which 
sequestra  have  healed  in  under  the  bismuth  treatment. 

The  second  cause  of  failure  is  found  in  not  using  the  paste 
soft  enough  to  permit  its  being  gently  forced  into  the  remotest 
parts  of  the  sinus  and  filling  it  completely.  If  some  small 
branch  is  missed  the  suppuration  will  continue  and  in  time  the 
entire  tract  will  bec^ome  reinfected. 

The  Course  of  Cases  Injected. — If  after  the  first  mjection  the 
purulent  discharge  changes  into  a  serous  one  a  good  result  is  to  be 
anticipated  and  closure  usually  follows.  Should  the  discharge 
remain  purulent,  however,  the  case  is  apt  to  prove  more  tedious. 
After  a  week  a  second  injection  is  made  and  subsequently  an 
injection  is  made  eA'ery  three  or  four  clays  for  about  a  month. 
Daily  dressings  with  frecpent  microscopical  examinations  of  the 
wound  discharge  are  made  during  this  time.  When  the  dis- 
charge no  longer  shows  microorganisms  a  10  per  cent,  paste  is 
substituted  for  the  greater  strength,  or  sterilized  vaselin  alone 
may  be  employed. 

If  no  improvement  is  noted  the  cause  of  failure  must  be  searched 
for. 

Dangers.  Toxic  Effects  following  the  Injection. — There  have 
been  reported  numerous  serious  cases  and  some  fatal  ones 
resulting  from  this  treatment.  Careful  observation  of  each  case 
and  the  use  of  the  paste  only  according  to  indications,  in  chronic 
suppurations  in  which  the  thick  walls  of  the  tracts  do  not  permit 
of  ready  absorption,  and  the  avoidance  of  its  use  in  acute  sup- 
purations will  prevent  fatalities.     The  first  symptom  of  slow 


HEMORRHAGE  257 

absorption  is  a  pale,  livid  tint  of  the  skin;  following  this  small 
bluish  ulcers  appear  on  the  gums.  Later  nausea,  headache, 
vomiting  and  albuminuria  supervene.  As  the  absorption  con- 
tinues the  ulceration  of  the  gums  increases,  the  patient  becomes 
emaciated  and  gradually  succumbs.  Close  observation  in  all 
cases  will  detect  the  early  manifestations  of  poisoning.  The 
injection  of  the  cavity  with  warm  sterile  olive  oil  which  is  al- 
lowed to  remian  from  twelve  to  twenty-four  hours  until  it  has 
formed  an  emulsion  with  the  paste  and  the  removal  of  this  emul- 
sion by  aspiration  will  prevent  the  further  appearance  of  unto- 
ward symptoms.  To  ensure  that  the  paste  is  removed  the  cavity 
can  again  be  injected  with  olive  oil  and  washed  out  several  times 
with  it. 


CHAPTER  VIII. 
HEMORRHAGE. 


Post-operative  hemorrhage.  Hemophiliacs.  Primary  oozing.  Second- 
ary hemorrhage.  Hemorrhage  from  vessels  of  large  caliber.  Hemorrhage 
due  to  loosening  of  the  ligature.  Hemorrhage  due  to  infection  or  erosion. 
Hemorrhage  due  to  vascular  paresis.  Hemorrhage  due  to  blood  clot. 
Diagnosis.  Treatment.  Treatment  of  late  secondary  hemorrhage.  Intra- 
venous sahne  infusion.  Intravenous  infusion  without  dissection.  Hypo- 
dermoclysis.  Autoinfusion.  Direct  transfusion.  Crile's  method.  Brew- 
er's method.     Elsberg's  method. 

Post-Operative  Hemorrhage.  Hemophiliacs. — Occasionally 
such  subjects  require  operation.  Whenever  possible  hemophiliacs 
should  be  treated  before  operation  by  administering  twenty- 
grain  doses  of  calcium  lactate  four  or  five  times  daily.  If  the 
necessity  for  the  operation  does  not  permit  of  delay  the  adminis- 
tration of  calcium  lactate  should  be  begun  immediately  following 
the  operation.  Saline  infusion  is  contraindicated,  but  copious 
hot  saline  enemata  should  be  employed.  The  inhalation  of 
carbon  dioxid  gas  has  some  effect  in  controlling  the  oozing. 
Thyroid  extract  is  useful  in  some  cases.  The  subcutaneous 
daily  injection  of  several  ounces  of  human  or  horse  serum  has 
proven  of  value.  The  oozing  is  best  controlled  by  direct  con- 
tinuous pressure  applied  to  tjie  source  of  hemorrhage.     Adrena- 

17 


258  OPERATING    EOOM    AND    THE    PATIEXT 

lin  solution  1  :  1000  may  be  applied  to  the  wound  as  a  temporary 
expedient.  Rectal  enemas  of  5  per  cent,  gelatin  solution  are 
sometimes  useful  but  may  result  in  embolism.  Ergot  is  ad- 
ministered by  mouth.  When  the  bleeding  has  been  finally 
arrested  the  patient  is  given  Blaud's  mass,  ten  grains,  three 
times  a  day,  and  the  diet  made  as  nutritious  as  possible. 

Primary  Oozing. — In  wounds  in  which  hemostasis  has  not 
been  exact,  or  in  which  large  areas  have  been  opened  up,  the 
primary  oozing  will  be  profuse.  At  the  time  of  the  operation, 
owing  to  the  depression  of  the  heart  from  the  anesthetic,  there 
msij  have  been  no  signs  of  oozing.  Upon  recovery  from  the 
anesthetic,  however,  and  upon  the  rising  blood  pressure  from  the 
patient  thrashmg  about  in  coming  out  of  the  anesthetic,  the  in- 
creasedVis  a  tergo  may  be  sufiicient  to  displace  the  small  blood  clots 
in  the  mouths  of  the  capillaries,  and  more  or  less  oozing  follows. 
Usually  this  is  not  sufficient  to  be  serious.  The  most  that 
happens  is  the  saturation  of  the  wound  dressings  with  bright  blood. 
The  dressings  should  be  changed  immediately  and  the  wound 
repacked.  If  the  dressings  are  not  changed  the  blood  will  form 
a  soft  clot  on  the  surface  of  the  wound  after  having  saturated 
the  dressings,  and  this  still  further  favors  bleeding.  In  case 
there  is  only  slight  primary  oozing,  not  sufficient  to  soak  tKe 
dressings,  it  is  only  necessary  to  apply  fresh  gauze  to  the  outside 
of  the  wound  dressing  and  to  bandage  snugly.  Primary  oozing 
favors  the  occurrence  of  infection  by  furnishing  a  culture  medium. 

Secondary  hemorrhage  may  occur  early  or  late  in  the  course  of 
wound  healing.  In  case  drainage  has  been  employed  the  blood 
will  usually  escape  externally  to  some  extent;  in  other  cases  the 
blood  will  escai^e  into  the  adjoining  tissues  or  into  a  cavity  of  the 
body.  Bleeding  ma}^  take  place  gradually  or  very  quickly.  In 
the  former  event  oozing  may  continue  from  the  time  of  the  opera- 
tion. As  the  depressing  effects  of  the  operation  and  anesthetic 
wear  off  and  the  heart  action  recovers  somewhat,  the  blood 
escapes  more  c[uickly  from  the  open  capillaries,  and  the  oozing, 
which  was  but  slight  at  the  time  of  operation,  and  seemingly  well 
controlled  by  simple  pressure,  may  assume  alarming  proportions. 
In  such  an  event  if  the  escape  of  blood  is  noticed  externally,  as 
in  the  case  of  operation  upon  the  surface,  it  is  not  probable  that 


HEMORRHAGE  259 

sufficient  blood  will  be  lost  to  be  dangerous  before  remedial 
measures  are  instituted.  If,  however,  as  in  operations  upon  the 
pelvic  viscera  where  many  adhesions  have  been  encountered,  the 
oozing  occurs  under  the  packing,  lifting  it  up  and  forming  soft 
clots  which  favor  further  oozing,  the  tell-tale  packing  and  drain- 
age strip  may  not  be  efficient  in  absorbing  more  than  a  very  small 
percentage  of  the  effused  blood,  the  remainder  escaping  into  the 
general  peritoneal  cavity  (concealed  hemorrhage).  Usually  in 
cases  which  ooze  somewhat  at  the  time  of  closing  the  wound  and 
in  which  packing  is  employed,  the  oozing  stops,  and  before  the 
depressed  heart  action  has  become  normal  coagula  of  sufficient 
strength  have  formed  in  the  open  ends  of  the  capillaries  to  with- 
stand the  increased  blood  pressure.  Such  a  happy  occurrence 
does  not  always  take  place,  therefore  cases  in  which  large  raw 
surfaces  are  present  must  be  carefully  watched.  The  oozing 
in  these  cases  is  very  insidious  and  the  symptoms  may  be  mis- 
taken for  prolonged  postoperative  shock.  This  belief  may  be 
maintained  and  measures  employed  to  combat  the  supposed 
shock,  with  the  result  of  raising  the  blood  pressure  and  producing 
further  bleeding. 

Hemorrhage  from  vessels  of  larger  caliber  may  occur  while  the 
patient  is  recovering  from  the  anesthetic.  Such  vessels  may 
have  passed  unnoticed  at  the  time  of  the  operation  as  the  blood 
pressure  was  not  sufficient  to  cause  more  than  a  trifling  oozing. 
During  the  involuntary  struggling  of  the  patient  while  recovering 
from  anesthesia  the  blood  pressure  is  raised  and  a  sharp  hemor- 
rhage ensues.  This  is  more  readily  diagnosed  than  the  insidious 
oozing  of  the  first  variety  of  secondary  hemorrhage,  which  has 
been  noted  above. 

Hemorrhage  Due  to  Loosening  of  the  Ligature. — If  the  ligature 
has  been  carelessly  tied — i.e.,  a  "granny"  in  place  of  a  square 
knot — bleeding  may  occur  at  any  time  within  twenty-four  hours. 
In  large  vessels  a  simple  square  knot  may  be  tied  in  place  of  a 
Ballance  and  Edmunds  stay  knot,  with  the  result  that  the  con- 
tinued impulses  from  the  heart  either  cause  the  knot  to  loosen  or 
to  be  pushed  off  the  cut  end  of  the  vessel.  For  this  reason  also 
the  ligature  should  not  be  placed  too  near  the  cut  end  of  a  large 
vessel.     Yet  another  cause  of  secondary  hemorrhage  is  to  be 


260  OPERATING    ROOM    AND    THE    PATIENT 

found  in  too  early  softening  of  the  ligature.  This  cause  is  rare 
except  in  the  case  of  large  vessels,  for  in  small  vessels  twenty-four 
or  at  the  most  forty-eight  hours'  ligation  is  sufficient  time  for  the 
vessel  to  become  firmly  occluded. 

Hemorrliage  Due  to  Infection  or  Erosion. — With  the  aseptic 
precautions  of  the  present  day,  hemorrhage  from  this  cause  is 
rare.  The  ligature  itself  may  be  the  cause  of  the  infection,  or 
infection  may  arise  in  the  surrounding  tissues  and  attack  the 
vessel  wall.  In  either  event  the  usual  time  for  such  hemorrhage 
to  occur  is  ten  days  after  the  ligature  is  applied.  Exceptionally 
the  vessels  themselves  are  involved  in  a  septic  process,  when 
erosion  of  the  vessel  wall  and  consequent  hemorrhage  may  occur 
at  any  time,  after  two  or  three  weeks  even,  during  the  activity 
of  the  septic  process. 

Hemorrhage  Due  to  Vascular  Paresis. — A  too  tightly  applied 
Esmarch  bandage  or  tourniquet,  or  one  which  has  been  left  in 
place  for  a  long  time,  four  to  ten  hours,  as  is  sometimes  necessary 
in  cases  of  traumatic  amputation  when  the  condition  of  the 
patient  does  not  permit  of  immediate  interference,  causes  a  pare- 
sis of  the  vessels  of  the  limb.  Several  hours  after  the  tour- 
niquet has  been  removed  and  when  the  blood-pressure  has  been 
raised  somewhat,  oozing  begins  and  may  continue  until  a 
dangerous  amount  of  blood  has  been  lost  unless  means  are  taken 
to  control  it. 

Hemorrhage  Due  to  Blood  Clot. — The  formation  of  soft  blood - 
clots  produced  by  an  insignificant  amount  of  oozing  may  result 
in  a  more  pronounced  hemorrhage,  as  bleeding  is  favored  by  the 
formation  of  such  clots. 

Diagnosis.— The  diagnosis  of  secondary  hemorrhage  with 
escape  of  the  blood  externally  is  a  simple  matter.  Such  also  is  the 
case  when  a  sudden,  sharp  hemorrhage  occurs,  even  when  there 
is  no  escape  of  blood  externally.  In  the  latter  the  blanched  lips, 
cold  skin,  restlessness,  rapid  and  panting  respiration  (air  hunger) , 
the  excessive  thirst,  and  subnormal  or  normal  temperature  with 
rapidly  weakening  and  increasing  pulse-rate  are  diagnostic.  In 
the  former  the  symptoms  may  not  become  so  severe,  for  the  escape 
of  blood  externally  will  serve  as  a  warning.  In  cases  of  slow 
oozing  with  escape  of  blood  externally  the  diagnosis  should  also 


HEMORRHAGE  261 

be  easily  made  before  severe  symptoms  develop.  In  those  cases 
of  oozing,  however,  in  which  there  is  but  slight  or  no  escape  of 
blood  externally  the  diagnosis  is  extremely  difficult.  One  does 
not  know  at  first  whether  one  is  dealing  with  a  case  of  prolonged 
shock  or  of  concealed  secondary  hemorrhage.  To  establish  a 
diagnosis  one  must  be  thoroughly  conversant  with  the  operative 
procedure  employed.  If  the  operation  has  been  one  involving 
the  separation  of  numerous  and  dense  adhesions,  there  has  prob- 
ably been  left  a  small  drain  as  a  tell-tale.  Should  there  be  no 
blood  or  but  slight  staining  upon  this,  remove  it,  and,  if  necessary, 
enlarge  the  opening  through  which  it  emerged  so  as  to' allow  of 
the  escape  of  fluid  blood. 

Treatment. — To  be  efficacious  treatment  must  not  only  be 
prompt  but  must  be  intelligently  directed.  Not  one  unnecessary 
drop  of  blood  should  be  allowed  to  be  lost.  Particularly  is  this 
true  in  the  case  of  young  children  and  old  people  who  bear  poorly 
the  loss  of  even  small  amounts  of  blood.  First,  by  a  review  of 
the  condition  present  at  the  operation,  the  probable  source  of 
the  hemorrhage  should  be  ascertained.  Second,  appropriate 
means  for  its  control  should  be  immediately  instituted.  Above 
all,  do  not  stimulate  the  circulation  until  this  bleeding  has  been 
effectually  stopped.  The  means  for  accomplishing  this  are  the 
same  as  those  used  at  the  operation.  Whether  or  not  Sn  anes- 
thetic may  be  employed  will  depend  upon  the  condition  of  the 
patient.  If  the  patient  is  not  much  depressed  by  the  loss  of 
blood,  and  the  source  of  hemorrhage  is  deeply  situated,  an 
anesthetic  may  be  given.  If  the  patient  is  much  weakened,  or 
if  the  bleeding  vessel  or  oozing  area  can  be  readily  reached,  it  is 
best  not  to  use  an  anesthetic.  If  the  restlessness  of  the  patient 
is  uncontrollable  an  anesthetic  must  be  used.  Every  bleeding 
point  is  to  be  secured,  either  by  direct  ligation  or  circumligature. 
It  may  be  necessary  in  some  cases  to  ligate  a  vessel  at  a  distance 
from  the  wound.  When  there  is  a  general  oozing  with  no  visible 
vessel  the  thermocautery  may  be  used,  but  styptics  are  never 
to  be  employed,  as  they  predispose  to  later  bleeding.  Tampon- 
ade in  cases  of  secondary  hemorrhage  may  be  used  to  supplement 
the  means  outlined  above.  In  hemorrhage  due  to  vascular 
paresis,  consider  whether  the  main  vessels  have  been  effectually 


262  OPERATING    ROOM    AND    THE    PATIENT 

ligated.  If  this  is  decided  in  the  affirmative,  do  not  remove  the 
inner  dressings.  Remove  the  outer  dressings  and  apply  fresh 
gauze,  then  apply  a  snugly  fitting  rubber  bandage  from  the  most 
distal  portion  of  the  extremity  to  the  former  site  of  the  constric- 
tor, elevate  the  part,  and  keep  it  quiet.  In  this  class  of  cases  the 
elastic  compression  controls  the  oozing  and  the  course  of  the 
wound  is  not  interfered  with.  The  tension  of  the  bandage  is 
lessened  every  twelve  hours. 

In  secondary  hemorrhage  occurring  under  large  flaps — as,  for 
example,  after  extensive  plastic  operations — before  removing 
the  sutures  and  thereby  endangering  the  success  of  the  operation, 
remove  the  dressings,  press  out  all  fluid  blood  and  particularly 
all  clots,  for  hemorrhage  continues  more  readily  under  soft 
blood-clots,  and  apply  firm,  even  pressure  to  the  part.  Though 
the  wound  dressing  may  be  soaked  with  blood,  this  does  not 
necessarily  mean  a  large  loss  of  blood,  as  gauze  is  very  hydro- 
scopic. It  will  usually  be  found  that  firm  pressure  is  sufficient, 
and  no  anxiety  need  be  felt,  particularly  if  one  is  certain  of  the 
accurate  ligation  of  the  larger  vessels.  In  wounds  of  the  surface 
which  have  been  packed  to  control  oozing,  and  in  which  clots 
form  in  and  beneath  the  gauze  and  hemorrhage  occurs,  the 
packing  should  be  removed,  the  wound  cleansed  of  clots,  and  a 
fresh  packing  introduced. 

When  the  site  of  the  hemorrhage  permits  the  Esmarch  bandage 
or  digital  compression  should  be  employed  until  more  radical 
means  can  be  used. 

Whenever  it  has  been  necessary  to  remove  the  sutures  and 
open  the  wound,  the  normal  wound  apposition  should  be  restored 
as  quickly  as  possible.  If  this  is  impracticable  at  the  time, 
secondary  closure  may  be  resorted  to  at  a  later  period.  Rigid 
asepsis  is  essential. 

In  the  treatment  of  late  secondary  hemorrhage  occurring  as  the 
result  of  erosion  of  a  vessel  from  sepsis,  control  is  at  times 
difficult.  A  slight  bleeding  may  precede  a  more  marked  hemor- 
rhage. The  wound  should  be  firmly  packed  and  the  part  ele- 
vated. In  the  case  of  an  extremity  the  joint  proximal  to  the 
wound  should  be  flexed  to  compress  somewhat  the  main  artery. 
If  bleeding  continues  the  vessels  must  be  isolated  and  ligated. 


HEMORRHAGE  263 

If  it  is  not  possible  to  do  this  in  the  wound  itself  by  reason  of  the 
septic  condition  present,  the  vessel  may  be  exposed  through 
healthy  tissue  at  a  distance  from  the  wound  and  there  ligated. 
In  desperate  cases  it  may  be  even  necessary  to  perform  an 
amputation  in  the  case  of  an  extremity. 

Following  or  coincident  with  the  control  of  the  hemorrhage 
various  procedures  are  instituted  to  overcome  the  effects  of  the 
bleeding. 

Intravenous  Saline  Infusion.  Indications. — In  cases  suffering 
from  shock;  in  cases  in  which  a  large  amount  of  blood  has  been 
lost;  in  cases  where  the  function  of  the  kidneys  has  been  sus- 
pended; in  cases  in  which  there  are  toxins  in  the  blood  the  rapid 
elimination  of  which  is  desired.  In  this  latter  class  are  septi- 
cemia and  delirium  tremens. 

Physiologic  Action. — In  the  amount  of  from  forty  to  sixty 
ounces  and  at  a  temperature  of  115°  F.,  intravenous  saline 
infusion  raises  the  blood  pressure  by  increasing  the  amount  of 
fluid  on  which  the  heart  can  work,  while  by  its  heat  it  stimulates 
all  the  body  functions.  The  disturbed  circulatory  rhythm  is 
reestablished. 

In  shock,  by  increasing  the  amount  of  fluid  upon  which  the 
heart  has  to  work,  the  great  volume  of  blood  which  has  been 
stored  up  in  the  abdominal  veins  is  forced  into  the  general 
circulation.  The  high  temperature  of  the  solution  is  of  inesti- 
mable benefit. 

In  hemorrhage  the  heart  is  given  fluid  with  which  to  carry  on 
its  work,  and  the  patient  stimulated  sufficiently  to  tide  him  over 
the  shock  from  the  loss  of  blood.  In  such  cases  the  infusion 
should  never  be  started  until  the  bleeding  point  is  secured.  In 
anuria  the  raising  of  the  blood  pressure  forces  the  kidneys  to 
perform  their  proper  function.  Whether  in  renal  insufficiency  or 
due  to  entrance  through  the  blood  by  absorption  from  the  in- 
testinal canal,  as  in  delirium  tremens,  or  the  lungs,  as  in  gas 
poisoning,  or  to  toxins  from  an  infected  wound,  the  virulence  of 
these  toxins  is  reduced  by  dilution  and  their  elimination  hastened 
by  raising  the  blood  pressure. 

Technic. — The  solution  used  should  be  6/10  per  cent,  sodium 


264 


OPERATING    ROOM    AXD    THE    PATIEXT 


chlorid  at  a  temperature  in  the  jar  of  120°  F.  A  special  saline 
powder  may  be  used. 

In  cases  in  which  secondary  hemorrhage  is  feared  care  should 
be  taken  not  to  raise  the  blood  pressure  too  high  by  introducing 
a  large  amount  of  saline.  The  solution  should  be  allowed  to 
flow  in  very  slowly. 

An  ordinary  irrigating  jar  with  sterile  tubing,  glass  connection 
and  infusion  cannula  is  used.  If  desired  an  apparatus  such  as 
shown  in  the  illustration  may  be  employed.     (Fig.  156). 


A  B 

Fig.  156. — Intravenous  saline  infusion.  A,  The  lower  ligature  is  tied 
and  the  upper  ligature  is  in  place  ready  for  tying.  The  valve-shaped 
opening  in  the  vein  is  shown  ready  to  receive  the  cannula.  B,  Flask  con- 
taining the  saline  solution.  This  flask  is  an  ordinary  wash-bottle,  the  long 
glass  tube  of  which  is  connected  to  the  infusion  cannula  and  the  short  glass 
tube  to  a  rubber  bulb  with  valves.  By  pumping  air  into  the  flask  above 
the  solution  the  latter  is  forced  into  the  vein.      (Fowler's  Surgery.) 


The  median  basilic  or  the  median  cephalic  vein  at  the  bend  of 
the  elbow  is  usually  selected.  A  constricting  bandage  (the 
fillet)  is  placed  around  the  upper  part  of  the  arm  so  as  to  obstruct 
the  return  flow  through  the  superficial  veins  but  not  tight  enough 
to  interfere  with  the  arterial  flow.  With  aseptic  precautions  the 
vein  is  bared  and  cleared  for  about  one  inch.  Two  ligatures  are 
passed  loosely  around  it,  one  above  the  point  of  intended  opening 


HEMORRHAGE  265 

and  one  below.  An  opening  small  and  valve-shaped  is  made  in 
the  vein  with  pointed  scissors,  the  tube  of  the  cannula  is  intro- 
duced therein,  first  allowing  some  of  the  infusion  fluid  to  flow 
through  it  in  order  to  guard  against  the  entrance  of  air.  The  upper 
ligature  is  now  tightened  around  the  cannula,  holding  it  in  place 
and  also  preventing  leakage.  The  lower  ligature  is  tied,  closing 
the  vein  below.  The  fillet  is  now  removed.  The  infusion  jar 
should  be  lifted  about  three  feet  above  the  vein.  The  rapidity 
of  the  flow  of  the  solution  can  be  regulated  by  raising  or  lowering 
the  jar  containing  the  saline. 

In  shock  it  may  be  desirable  to  combine  small  doses  of  adrena- 
lin chlorid  in  1  :  1000  solution  with  the  saline  infusion.  This 
may  be  done  by  introducing  the  hypodermic  needle  into  the 
rubber  tubing  and  slowly  injecting  the  adrenalin  into  the  saline. 
This  may  be  repeated  at  intervals  of  every  few  minutes  (Crile) 
until  the  blood  pressure  is  manifestly  raised.  In  cases  of  shock 
in  which  strychnin  has  been  administered  before  the  saline 
infusion  is  started  there  is  always  a  risk  that  the  saline  infusion 
will  cause  the  strychnin  to  be  absorbed  too  rapidly.  In  such 
cases  symptoms  of  strychnin  poisoning  may  develop. 

Intravenous  Infusion  without  Dissection. — A  needle  having  an 
cbtuse-angle  point  (Fig.  157)  is  substituted  for  the  intravenous 


Fig.  157. — Needle  for  intravenous  infusion  without  dissection. 

cannula.  Without  previous  dissection  the  needle  is  thrust  into 
the  distended  vein  at  an  oblique  angle  while  the  saline  is  flowing. 
Otherwise  the  procedure  is  the  same  as  ordinary  intravenous 
infusion.  With  a  little  practice  the  introduction  of  the  needle 
into  the  vein  is  quite  simple. 

Hypodermoclysis. — In  cases  which  are  not  so  urgent  hypoder- 
moclysis  may  be  substituted  for  intravenous  saline  infusion. 
The  apparatus  consists  of  two  hollow  needles,  a  Y-connection, 


266  OPERATING    ROOM    AND    THE    PATIENT 

rubber  tubing,  and  an  ordinary  bulb  syringe  or  an  irrigator. 
The  needles  are  introduced  into  the  cellular  tissues  beneath  each 
breast  and  from  one  to  two  pints  of  the  solution  slowly  intro- 
duced, usually  a  pint  beneath  each  breast.  Gentle  massage  of 
the  parts  helps  to  diffuse  the  fluid.  This  is  rapidly  absorbed. 
Should  a  second  hypodermoclysis  be  indicated,  it  may  be  given 
in  the  interscapular  region  or  the  inner  surface  of  the  thigh. 

Autotransfusion. — Autotransfusion,  like  intravenous  saline  in- 
fusion, should  only  be  employed  after  the  source  of  hemorrhage 
is  under  control.  In  cases  of  shock  it  is  used  to  favor  the  cardiac 
and  respiratory  centers  in  the  medulla.  In  such  cases  the  foot 
of  the  bed  is  raised  to  an  angle  of  forty-five  degrees.  This  tends 
to  force  the  blood  to  the  medulla.  In  cases  of  hemorrhage  after 
the  bleeding  point  has  been  secured,  one  or  all  of  the  extremities 
may  be  bandaged,  beginning  at  the  most  distal  point  and  bandag- 
ing toward  the  trunk,  thus  forcing  the  blood  of  the  extremities 
into  the  body  circulation.  This  is  of  great  value  as  a  temporary 
resource.  It  does  not  take  the  place  of  intravenous  saline  in- 
fusion, but  may  be  used  to  gain  time  and  tide  the  patient  over 
while  the  saline  infusion  is  being  prepared.  The  extremities 
should  not  be  kept  bandaged  in  this  manner  for  longer  than  two 
hours. 

Direct  Transfusion. — The  two  main  indications  for  direct 
transfusion  are  hemorrhage  and  shock.  It  is  also  indicated  in 
hemophilia  and  cholemia.  In  shock,  according  to  Crile,  direct 
transfusion  causes  a  greater  and  more  prolonged  effect  upon  the 
blood  pressure  than  does  the  intravenous  injection  of  saline. 
In  toxic  conditions  of  the  blood,  such  as  delirium  tremens, 
complicating  operations,  dii'ect  transfusion  is  indicated.  These 
latter  conditions  may  be  likened  to  gas  poisoning,  in  which 
venesection  followed  by  transfusion  is  the  treatment  par 
excellence. 

Dangers.  Hemolysis. — The  present  tests  for  hemolysis  are 
not  practical  in  emergency  work  as  they  recpire  twenty-four 
hours  for  their  performance.  ^Tienever  feasible  such  tests 
should  be  made  between  the  donor's  corpuscles  and  the  recipient's 
serum  and  the  recipient's  corpuscles  and  the  donor's  serum. 
Hemolvsis  in  the  former  case  is  not  necessarilv  harmful  but  in 


HEMOERHAGE 


267 


the  latter  another  donor  must  be  chosen.  In  emergency  cases 
to  prevent  the  danger  of  hemolysis  as  much  as  possible  the 
donor  should  be  chosen  from  among  the  relatives  of  the  patient, 
using  as  close  a  blood  relation  as  possible.  In  any  event  the 
donor  must  be  free  from  constitutional  or  other  disease. 

erne's  Method.^ — The  radial  artery  of  the  donor  and  any 
superficial  vein  of  the  recipient  (usually  a  vein  in  the  forearm) 
is  utilized.  Twenty  minutes  before  the  transfusion  both  donor 
and  recipient  are  given  a  hypodermic  injection  of  morphin. 
The  usual  aseptic  preparation  of  the  parts  is  made.  The  eyes  of 
both  are  covered.  The  table  on  which  the  donor  is  placed 
should  have  the  Trendelenburg  attachment  so  that  in  case  of 


y 

Table  for 
IfGoipient 

6 

m    ^ 

3 

0 

7 

Table/or 
^         Donor 

Fig.  158. — Arrangement  of  patient  for  direct  transfusion.  1,  Table  for 
recipient;  2,  table  for  donor;  3,  table  for  arms  of  recipient  and  donor;  4  and 
5,  stools  for  operator  and  assistant;  6,  instrument  and  dressing  table;  7, 
saline  irrigator. 


syncope  the  head  can  be  rapidly  lowered.  The  recipient  is 
placed  on  a  table  with  the  head  in  the  opposite  direction  from 
the  donor.  The  relative  position  of  the  recipient,  donor,  operator 
and  assistant  is  shown  in  the  accompanying  diagrammatic  sketch 
(Fig.  158).  Under  local  anesthesia  about  3  c.c.  of  the  donor's 
radial  artery  at  the  wrist  is  exposed  and  the  smaller  branches 
tied  with  very  fine  silk.  A  Crile  clamp  (Fig,  159)  is  applied  to 
the  proximal  end  of  the  artery  and  the  distal  end  ligated.     The 

^  Philadelvhia  Lancet,  Aug,,  1907,  vol.  xl,  pp.  1057-1068. 


268 


OPERATING    ROOM    AND    THE    PATIENT 


artery  is  then  divided,  the  adventitia  pulled  over  the  free  end 

as  far  as  possible  and  snipped  off  close.     The  field  is  now  covered 

with  a  wet  saline  sponge.     Three  or  4  cm.  of  the  superficial 

vein  of  the  recipient  is  exposed,  the  distal  part  ligated  and  the 

proximal   end    closed   with    a    Crile 

clamp.       The     distal    part     is    then 

divided  with  scissors,  the  adventitia 

being  drawn   out   as  far   as  possible 

and    snipped    off    close.     A    cannula 

(Fig.    160)    is    selected    the   bore    of 

which  is  larger  than  the  natural  tissue 

thickness    of   either   vein    or  artery. 

The  vein  is  then  pushed  through  the 

cannula    with    the    free    end    drawn 

back  at  the  cuff  and  snugly  tied   in 

the  second  groove.     To  facilitate  the 

procedure   the  handle  of  the  cannula 

is   manipulated    with   forceps.      The 

3,  clamp  applied  to  artery,    artery  is  then  drawn  over  the  vein 
(Fowler's  Surgery.)  ''         ,      ^.    ,       v.  n    T 

and  snugly  tied  with  a  small   Imen 

ligature  in  the  first  groove.     Should  the  artery  be  atheromatous 

or  for  any  reason  contracted,  its  lumen  may  be  dilated  by  means 

of  a  mosquito  hemostat  pushed  into  its  lumen  and  gradually 

opened.     The  vein  clamp  is  removed,  then  gradually  the  artery 


1 


2  3 

-1,  Crile's  clamp; 


Fig.  159 
2,  rubber  tubing  for  slipping 
over  the  ends  of  the  clamps; 


Fig.   160. — Crile's  cannulse. 


clamp.  At  this  point  the  blood  will  be  seen  to  pass  from  the 
artery  across  to  the  vein  dilating  the  latter.  Exposure  and 
manipulation  of  the  vessels  will' cause  them  to  contract,  particu- 
larly so  in  the  case  of  the  artery  which  may  contract  sufficiently  to 
obliterate  its  lumen.     A  constant  gentle  stream  of  warm  saline 


HEMORRHAGE 


269 


solution  by  keeping  the  vessels  from  the  air  will  materially  aid 
in  bringing  about  relaxation.  The  pulse  wave  may  be  palpated 
in  the  vein.  It  is  best  to  introduce  the  blood  very  slowly.  If 
allowed  to  pass  too  rapidly  in  cases  in  which  the  recipient's  cardiac 
muscle  is  weak  symptoms  of  acute  cardiac  dilatation  may  occur. 
Distressing  symptoms  which  occasionally  occur  and  which 
call  for  temporary  cessation  of  the  transfusion  with  the  Crile 
clamp  are  cardiac  distress,  uneasiness,  coughing,  rapid  pulse 
and  cyanosis.  These  symptoms  pass  off  after  a  time.  The 
transition  in  the  recipient  is  striking.  In  shock  and  hemorrhage 
there  is  a  gradual  alteration  of  the  pale  haggard  facies  and  a 
substitution  of  pink  coloration.  In  the  donor  after  from  twenty 
to  forty-five  minutes  of  continuous  flow  from  the  radial  artery  a 
gradual  pallor  of  the  face  and  ears  may  be  noted,  and  serious 


Fig.  161. — Brewer's  tubes. 

effects  will  be  observed  if  the  transfusion  is  allowed  to  go  on. 
The  transfusion  should  be  terminated  as  soon  as  the  donor  shows 
irregular  respiration,  or  sighs,  or  becomes  uneasy,  or  presents 
any  of  the  evidences  of  the  loss  of  blood.  The  earliest  and  most 
constant  change  noted  in  the  recipient  is  the  almost  instant  and 
continuous  rise  in  blood  pressure  continued  up  to  a  certain 
point  the  total  rise  depending  upon  the  physical  state  and  the 
quantity  of  blood  transfused.  There  is  also  a  rise  in  the  hemo- 
globin and  the  red  blood  count.  The  most  constant  phenomenon 
on  the  part  of  the  donor  is  increased  leucocytosis. 

Brewer's  Method. — Brewer  employs  glass  tubes  two  and  one- 


270  OPERATING    ROOM    AXD    THE    PATIENT 

half  inches  long  of  various  shapes  (Fig.  161)  someT\-hat  bulbous 
at  the  ends,  smaller  at  the  artery  end  and  larger  at  the  vein  end. 
There  is  a  depression  near  each  end  in  which  the  ligature  securing 
the  vessel  rests.  The  tubes  are  sterilized,  dipped  in  melted 
paraffin,  shaken  briskly  and  allowed  to  cool.  The  vessels 
selected  for  the  procedure  are  exposed  and  prepared  and  two 
Crile  clamps  applied  in  the  usual  manner.  The  artery  is  then 
drawn  over  one  end  of  the  tube  and  secured  by  a  ligature.  The 
Crile  clamp  on  the  artery  is  loosened  sufficiently  to  permit  the 
blood  to  fill  the  tube,  the  distal  end  of  which  is  then  inserted  into 
the  vein  and  secured  by  a  ligature.  The  clamps  are  then  removed 
and  the  transfusion  allowed  to  proceed. 


Fig.  162. — Elsberg's  cannula. 

Elsherg's  Method. — The  cannula  (Fig.  162)  is  built  on  the  prin- 
ciple of  a  monkey-wrench,  and  can  be  enlarged  or  narrowed  to 
any  size  desired  by  means  of  a  screw  at  its  end.  The  smallest 
lumen  obtainable  is  about  equal  to  that  of  the  smallest  Crile 
cannula,  and  the  largest  greater  than  the  lumen  of  any  radial 
artery.  The  instrument  is  cone-shaped  at  its  tip,  a  short  distance 
from  which  is  a  ridge  with  four  small  pin-points  which  are  directed 
backward.  The  lumen  of  the  cannula  at  its  base  is  larger  than  at 
the  tip. 

The  radial  aii:ery  of  the  donor  is  exposed  and  isolated  in  the 
usual  manner.  The  cannula,  screwed  wide  open,  is  then  slipped 
under  and  around  the  vessel.     It  is  then  screwed  shut  until  the 


COMPLICATIONS    OF    WOUND    INFECTIONS  271 

two  halves  of  the  instrument  slightly  compress  the  vessel.  The 
artery  is  then  tied  off  about  one  centimeter  from  the  tip  of  the 
cannula.  Before  the  vessel  is  divided  three  small  eye  tenacula 
are  passed  through  the  wall  of  the  artery  at  three  points  of  its 
circumference,  a  few  millimeters  from  the  ligature.  Small  mos- 
quito forceps  may  also  be  used.  These  are  given  to  an  assistant, 
who  makes  traction  on  them  while  the  operator  cuts  the  vessel 
near  the  ligature.  The  moment  the  artery  is  cut  the  stump  is 
pulled  back  over  the  cannula  by  means  of  the  tenacula  or  forceps, 
and  is  held  in  place  without  ligation  by  the  small  pin-points. 
There  is  no  bleeding  from  the  artery,  even  though  no  hemostatic 
clamp  has  been  applied,  because  the  cannula  itself  acts  as  a  he- 
mostatic clamp.  The  vein  of  the  recipient  is  then  exposed,  but 
not  freed,  two  ligatures  are  passed  around  it;  one  is  tied  peripher- 
ally in  the  usual  manner.  A  small  transverse  slit  is  made  in  the 
vein,  the  cannula  with  the  cuffed  artery  inserted  into  the  vein, 
a  ligature  tied  around  the  vein  and  cannula,  the  cannula  screwed 
open,  and  the  blood  allowed  to  flow.  The  rapidity  of  the  flow  can 
be  varied  as  desired  by  the  size  to  which  the  instrument  is  screwed 
or  unscrewed,  and  the  lumen  of  the  artery  is  never  diminished. 
Following  the  control  of  the  hemorrhage  and  the  treatment  of 
its  immediate  effects  by  the  above  measures  further  fluid  is 
furnished  the  tissues  by  the  introduction  of  saline  by  rectum. 
This  is  accomplished  by  giving  a  pint  to  a  quart  of  saline  every 
three  or  four  hours,  allowing  thirty  minutes  for  its  administra- 
tion, or  by  proctoclysis  by  the  Murphy  method. 


CHAPTER  IX. 
COMPLICATIONS  OF  WOUND  INFECTIONS. 

Lymphangitis.  Cellulitis.  Lymphostasis.  Lymphatic  edema.  Rectu- 
bular  lymph  phlegmon.  Tubular  phlegmon.  Lymphadenitis.  Septicemia. 
Pyemia.  Erysipelas.  Erysipelas  buUosum.  Hospital  gangrene.  Malig- 
nant edema.  Infectious  emphysema.  Bacillus  pyocyaneus  infection. 
Tetanus.    Trismus  associated  with  paralysis  of  the  facial  nerve. 

Lymphangitis. — Lymphangitis  is  the  result  of  infection  of  the 
lymphatic  channels  in  the  neighborhood  of  an  infected  wound. 
Clinically  we  find  two  forms  of  lymphangitis.     In  the  first  there 


272  OPERATING    ROOM    AND    THE    PATIENT 

is  a  circumscribed  patch  of  reddened  and  edematous  skin  in  the 
neighborhood  of  the  infected  wound.  This  may  persist  even  after 
the  infection  in  the  wound  has  subsided.  The  anatomical  reason 
for  such  an  isolated  patch  of  lymphatic  infection  resides  in  the 
fact  that  in  such  cases  onl}^  a  small  area  of  minute  lymph  vessels 
is  involved.  The  infection  in  such  an  area  may  extend  to  the 
larger  lymph  trunks  and  be  carried  to  distant  glands  even  after 
the  wound  infection  has  subsided.  When  the  larger  lymph 
trunks  are  involved  thrombi  may  be  felt  as  hard  cords.  The 
overlying  skin  is  reddened  in  streaks.  These  streaks  run  parallel 
to  one  another  and  extend  from  the  reddened  area  in  the  neighbor- 
hood of  the  wound  to  a  considerable  distance  along  the  course  of 
the  lymphatics.  The  infection  extending  through  the  walls  of 
the  lymphatics  involves  the  cellular  tissues,  and  so  cellulitis  with 
an  increase  in  the  redness  of  the  overlying  parts  and  swelling 
develops.  Should  a  considerable  number  of  lymph  channels  be 
involved,  lymphostasis  occurs  and  lymphatic  edema  complicates 
the  already  existing  inflammatory  swelling.  Usually  upon  dis- 
infection of  the  wound  and  suitable  drainage  these  symptoms 
subside,  though  suppuration  may  ensue.  In  such  an  event 
abscesses  develop  along  the  course  of  the  infected  lymphatic 
trunks.  These  abscesses,  unless  opened  early,  finally  coalesce 
and  form  one  elongated  suppurative  focus. 

Treatment. — The  wound  itself  should  be  vigorously  disin- 
fected. The  reddened  areas  in  its  neighborhood  {rectubular 
lymph  phlegmon)  or  reddened  strips  {tubular  lymphangitis) 
should  be  covered  by  large  compresses  wrung  out  of  alcohol- 
bichlorid  solution,  to  which  tincture  of  opium  in  the  proportion 
of  one  ounce  to  a  pint  of  the  solution  is  added  to  alleviate  the 
pain.  Upon  the  subsidence  of  the  acute  inflammation  mercurial 
ointment  may  be  gently  rubbed  along  the  thickened  lymphatic 
trunks.  In  isolated  lymphatic  infection  ichthyol  in  lanolin  may 
be  gently  rubbed  over  the  area.  Should  suppuration  ensue  the 
infected  foci  should  be  thoroughly  opened  and  dressed  and 
treated  as  infected  wounds. 

Lymphadenitis. — Lymphadenitis  may  occur  with  or  without 
preceding  lymphangitis.  It  is  more  apt  to  occur  with  only  a 
slight  degree  of  lymphangitis,  for  the  reason  that  in  severe  cases 


COMPLICATIONS    OF    WOUND    INFECTIONS  273 

of  lymphangitis  the  lymph  channels  become  blocked  and  so  the 
infection  cannot  be  carried  to  the  nearest  lymphatic  glands. 
The  lymph  glands  through  which  the  lymphatic  channels  in 
relation  with  the  wound  drain  may  become  swollen;  with  the 
subsidence  of  the  infection  in  the  wound  these  swollen  glands 
usually  become  normal.  If  the  infection  is  severe  or  prolonged 
the  lymph  glands  undergo  suppurative  changes  and  abscesses 
result.  It  quite  often  happens  that  only  a  portion  of  the  inflamed 
lymphatic  gland  undergoes  suppurative  changes,  the  pus  escapes 
through  the  gland  capsule,  infiltrates  the  surrounding  tissues, 
finds  an  exit  for  itself  externally,  or  an  opening  is  made  by  the 
surgeon  and  a  sinus  forms.  This  sinus  connects  with  the  in- 
flamed gland  and  is  persistent. 

Treatment. — The  original  wound  must  be  disinfected  and  thor- 
ough drainage  instituted.  This  will  usually  result  in  the  sub- 
sidence of  the  lymphadenitis,  but  it  may  happen  that  the  lymph- 
adenitis persists  after  the  original  focus  of  infection  has  healed. 
In  such  a  case  the  lymphadenitis  ma}^  remain  as  a  chronic 
hyperplasia  of  the  glands,  or  if  the  infection  has  been  severe 
suppuration  may  occur.  In  the  first  instance  if  inunctions  of 
mercurial  or  ichthyol  ointment  do  not  cause  the  hyperplasia  to 
subside,  the  glands  should  be  removed  if  considerably  enlarged. 
Small  glands  need  not  be  interfered  with  unless  they  are  a  source 
of  annoyance  to  the  patient.  Glands  palpably  the  seat  of 
infection  and  in  which  there  is  certainty  of  suppurative  changes 
should  be  opened  and  all  gland  tissue  removed.  Suppurating 
glands  which  have  opened  spontaneously  with  the  formation  of 
a  sinus  should  be  excised. 

Septicemia. — Before  the  advent  of  antisepsis  and  asepsis 
septicemia,  together  with  pyemia  and  hospital  gangrene,  were 
the  chief  causes  of  death  following  operations  and  injuries.  At 
the  present  time  these  diseases  are  rarely  seen,  and  then  only 
when  there  has  been  a  failure  to  apply  or  to  maintain  aseptic 
and  antiseptic  measures. 

The  advent  of  septicemia  is  marked  by  a  rise  of  temperature 
varying  from  101°  to  105°  F.  This  occurs  within  the  first  few 
days  after  the  operation.  Chills  are  rarely  observed,  and  even 
when  they  occur  in  the  outset  of  the  disease  they  are  not  repeated. 

18 


274  OPERATIXG    ROOM    AND    THE    PATIENT 

In  this  respect  the  disease  differs  from  pyemia.  The  pulse 
rises  to  120  or  higher.  The  tongue  is  dry  and  leather-like. 
When  the  patient  is  asked  to  show  his  tongue  it  protrudes  in  a 
hesitating  and  trembling  way.  The  lips  are  parched.  The  skin 
is  hot  and  drj^  and  of  a  dirty  brownish  color;  in  severe  cases  it 
may  be  pale  yellowish  and  there  may  be  petechise.  With  more 
pronounced  disintegration  of  the  blood  in  the  later  stages  of  the 
disease  hematogenous  icterus  may  occur.  Characteristic  changes 
occur  in  the  blood.  The  granulations  in  the  wound  are  fiabbj^ 
and  covered  with  a  thin,  gray,  offensive  discharge;  there  is  a  foul 
odor  to  the  wound.  There  is  anorexia.  As  a  rule,  the  bowels 
are  constipated,  but  in  severe  cases  there  may  be  profuse  and 
at  times,  bloody  diarrhea.  The  respirations  are  rapid  and 
superficial.  The  mental  attitude  is  one  of  indifference.  The 
disease  usually  proves  fatal  in  from  five  to  fourteen  days.  In 
those  cases  which  recover  there  is  remission  of  the  fever,  preceded 
by  sweating,  the  mental  condition  becomes  more  acute,  the 
respirations  deeper  and  less  rapid,  the  wound  becomes  healthier 
and  shows  a  tendency  to  heal.  In  the  fatal  cases  coma  develops, 
the  temperature  becomes  subnormal,  and  the  pulse  extremely 
rapid  and  feeble. 

Treatment. — As  soon  as  a  foul  odor  to  the  wound  is  noted,  and 
this  is  one  of  the  earliest  symptoms  of  septicemia  the  wound 
should  be  opened  up  in  its  entirety  and  thoroughly  cleansed, 
decomposing  and  sloughing  tissues  should  be  curetted  away,  the 
wound  thoroughly  irrigated,  absolutely  free  and  efficient  drainage 
provided,  and  a  10  per  cent,  solution  of  chlorid  of  zinc  should 
be  applied  to  the  wound  surfaces.  Should  the  medullary  tissue 
of  a  bone  be  involved,  in  case  the  disease  has  attacked  a  joint, 
resection  or  amputation  should  be  done  at  once.  The  general 
treatment  of  the  patient  should  be  supportive.  Of  the  drugs 
W'hich  prove  valuable  in  these  cases  quinin  and  alcohol  seem  the 
most  efficient.  Alcohol  may  be  given  in  the  form  of  beer,  one 
bottle  three  times  daily.  Oxygen  should  be  given  to  increase 
the  function  of  the  red  blood  cells.  A  solution  of  yeast  may  be 
used  to  irrigate  the  wound,  and  yeast  may  be  given  internall3^ 

A  stock  poh^'alent  vaccine  should  be  immediately  given 
pending  a  blood  culture  and  a   culture  from  the  wound.     A 


COMPLICATIONS    OF    WOUND    INFECTIONS  275 

vaccine  is  prepared  from  the  blood  culture  but  if  this  is  sterile 
as  not  infrequently  happens,  a  vaccine  can  always  be  prepared 
from  the  wound.  Both  cultures  are  made  simultaneously  to 
avoid  delay.  This  autogenous  vaccine  is  immediately  admin- 
istered. 

Pyemia. — This  disease,  like  septicemia,  is  now  rarely  seen. 
When  it  does  occur  it  is  almost  always  the  result  of  neglect  upon 
the  part  of  the  patient  or  his  attendant.  It  may  not  become 
manifest  for  from  five  days  to  several  weeks  after  the  wound  has 
become  infected.  At  first  there  is  an  infected  wound  with  the 
usual  daily  rise  and  fall  of  temperature.  After  a  few  days  there 
develops  a  chill,  followed  by  a  higher  rise  of  temperature,  and 
local  symptoms  at  a  point  distant  from  the  wound,  showing  the 
presence  of  metastatic  infection.  The  temperature  may  go  as 
high  as  105°  F.  The  local  symptoms  of  the  metastasis  will 
depend  upon  its  situation.  The  most  frequent  location  is  in  the 
lungs,  usually  near  the  periphery  of  the  lung.  In  such  a  case 
there  would  be  cough  with  the  physical  signs  of  infiltration  and 
softening.  When  near  the  pleura,  pleuritis  follows,  either  serous, 
or  seropurulent,  or  even  suppurative.  A  portion  of  the  lung 
may  become  gangrenous.  Occasionally  we  see  cases  of  diffuse 
lobar  pneumonia  surrounding  a  single  metastatic  abscess. 

Next  in  frequency  the  liver,  kidneys,  and  spleen  are  invaded. 
In  the  case  of  the  liver  and  spleen  there  will  be  tenderness  over 
these  organs  with  localized  pain.  In  the  case  of  the  kidneys  pus 
will  be  found  in  the  urine. 

The  tendinous  attachments  of  muscles  are  apt  to  be  involved, 
also  the  joints  and  serous  membranes.  The  knee-joint,  hip- 
joint,  and  elbow-joint  are  the  joints  most  frequently  involved. 
With  each  metastasis  there  occurs  a  chill  and  an  exacerbation  of 
the  fever.  As  the  metastatic  deposits  increase  in  number  chills 
become  less  frequent,  and  there  is  less  exacerbation  of  the  fever. 
Finally  the  patient  dies  of  asthenia.  The  general  symptoms  are 
those  of  prolonged  fever. 

Treatment. — The  recovery  of  the  patient  depends  upon  the 
thorough  disinfection  of  the  primary  focus  and  the  opening  up 
and  draining  of  the  metastic  deposits  as  they  occur.  As  these 
deposits  may  occur  in  any  part  of  the  body,  and  as  each  deposit 


276  OPERATING    ROOM    AND    THE    PATIENT 

forms  a  focus  from  which  other  deposits  may  arise,  it  is  easil}" 
seen  how  hopeless  is  the  prognosis.  If  the  case  is  seen  and  the 
disease  is  recognized  before  the  occurrence  of  many  metastases 
there  is  some  hope  that  by  the  disinfection  of  the  original  focus 
and  by  vaccine  therapy  the  course  of  the  disease  may  be  stayed. 
If  the  original  focus  is  on  one  of  the  extremities,  and  symptoms  of 
metastasis  in  important  internal  organs  have  not  developed, 
an  immediate  amputation  should  be  made.  In  case  of  an  in- 
fected thrombus  in  one  of  the  large  veins  either  of  the  neck  or  of 
the  extremities  double  ligation  with  excision  of  the  infected 
portion  of  the  vein  should  be  done.  In  other  respects  treatment 
is  the  same  as  for  septicemia. 

Erysipelas. — The  onset  of  the  disease  is  rapid.  There  is  a 
continuous  rise  of  temperature.  Usually  an  initial  chill  occurs. 
Sweating  is  rare.  Nausea  and  vomiting  generally  follow  the 
chill.  There  is  anorexia.  The  temperature  is  irregular  and 
progressively  rises  as  fresh  areas  are  involved.  The  duration  of 
the  disease  is  about  a  week;  the  subsidence  of  the  attack  is 
characterized  by  remission  of  the  morning  temperature. 

Wound  Appearance.— Except  in  erysipelas  of  the  scalp  (p.  352) 
the  skin  in  the  neighborhood  of  the  wound  is  intensely  red.  It 
is  differentiated  from  lymphangitis  by  the  absence  of  red  streaks. 
The  disease  usually  advances  in  the  direction  of  the  lymphatic 
current.  The  patch  of  redness  is  irregular,  there  is  increased 
heat  and  but  slight  edema.  In  erysi'pelas  hullosum  there  is  pro- 
fuse exudation  of  reddish  serum  with  the  formation  of  vesicles. 
These  follow  the  stage  of  redness  and  resemble  the  blisters 
following  a  burn.  Suppuration  may  occur  in  them.  A  phleg- 
monous inflammation  of  the  subcutaneous  tissues  may  com- 
plicate the  erysipelas.  The  inflammation  may  be  severe  enough 
to  culminate  in  gangrene.  In  such  a  case  there  is  first  the 
formation  of  blisters  and  brownish-red  spots,  which  afterward 
change  to  black.  This  gangrenous  process  shows  the  same 
tendency  to  spread  as  does  ordinary  erysipelas.  Erysipelatous 
inflammation  may  be  carried  to  distant  portions  of  the  body. 

Complications. — Transient    albuminuria    may    occur.     Bron- 

'chitis  is  a  frequent  complication.     According  to  the  location  of 

the  erysipelas,  the  various  serous  membranes  may  be  affected; 


COMPLICATIONS    OF    WOUND    INFECTIONS  277 

for  instance,  in  erysipelas  of  the  scalp  the  meninges  may  be  in- 
volved; in  erysipelas  of  the'chest  wall,  the  pleura;  in  the  case  of 
the  abdomen,  the  peritoneum;  in  the  case  of  joints,  the  synovial 
membrane. 

Predisposition. — The  scalp  seems  to  be  specially  predisposed 
to  erysipelas.  It  may  follow  operations  for  the  removal  of 
long-standing  tumors  in  which  the  skin  over  the  tumor  has 
become  thin  and  atrophic.  It  occurs  more  frequently  in  weak 
individuals  with  tender  skins.  The  loss  of  a  large  amount  of 
blood  seems  to  favor  the  occurrence  of  the  disease. 

Treatment. — Immediately  upon  the  discovery  of  the  disease 
the  case  should  be  isolated  and  all  articles  which  come  in  contact 
with  the  patient  in  any  way  should  be  boiled  before  being  again 
used.  The  attendant  who  dresses  the  wounds  of  a  patient  suffer- 
ing from  erysipelas  should  not  come  near  any  other  wound. 
After  each  visit  to  his  patient  he  should  use  every  possible  means 
of  disinfection  to  avoid  carrying  the  disease.  All  dressings 
should  be  burned.  General  supportive  treatment  of  the  patient 
is  indicated.  An  injection  of  streptococcic  vaccine  is  given  im- 
mediately (p.  349).     An  autogenous  vaccine  should  be  prepared. 

Local  Treatment. — The  erysipelatous  area  should  be  covered 
by  large  moist  dressings  of  either  carbolic  acid,  bichlorid  of 
mercury  or  alcohol.  As  the  streptococci  proliferate  most 
rapidly  in  the  margins  of  the  inflammation  it  is  here  that  the 
skin  should  be  injected  with  carbolic  acid  or  alcohol-bichlorid 
1  :  5000,  or  with  salicylic  acid  solution.  Tincture  of  opium  may 
be  added  to  the  antiseptic  dressing  in  the  proportion  of  two 
ounces  to  the  pint  to  allay  pain.  Scarification  of  the  skin  at  the 
margin  of  the  area  is  of  value. 

Hospital  Gangrene. — Hospital  gangrene  is  rarely  seen  at  the 
present  time.  The  appearance  of  the  wound  is  that  of  a  septic 
inflammation  of  a  granulating  surface  with  coagulation  necrosis 
of  the  outer  layer  of  the  granulations. 

This  necrosis  of  the  granulations  with  coagulation  of  fibrin  on 
them  resembles  a  diphtheria  patch  in  its  dirty  grayish-brown  color. 
The  granulations  fuse  together,  minute  abscesses  form,  and  ulcera- 
tion follows.  There  is  usually  profuse  exudation.  The  granu- 
lations become  swollen  and  grayish  white;  following  this,  gang- 


278  OPERATIXG    ROOM    AND    THE    PATIEXT 

rene  of  the  -u-ound  occurs.  In  one  part  of  the  wound  there  may 
be  a  diphtheritic  patch;  in  another  part,  necrosis  of  the  granula- 
tions with  minute  abscesses;  in  another  part,  a  pulpy  condition 
of  the  granulations  with  profuse  exudation;  in  another  part  a 
gangrenous  condition.  As  long  as  the  granulations  are  not  broken 
down,  no  general  symptoms  occur.  "With  the  destruction  of 
the  granulations,  however,  the  infection  becomes  general.  The 
rise  of  temperature  is  not  high;  it  may  even  remain  normal,  or 
become  subnormal.  There  is  profound  depression.  Pyemia  may 
develop. 

Treatment. — The  treatment  is  largely  preventive.  With  proper 
aseptic  and  antiseptic  precautions  and  the  proper  care  of  the 
granulations  the  disease  should  not  occur.  When  it  does  occur, 
however,  the  wound  should  be  promptly  curetted  and  should 
be  redressed  every  six  hours.  Wet  dressings  of  either  carbolic 
acid  or  alcohol-bichlorid  should  be  employed.  At  each  change 
of  dressing  the  granulations,  which  will  be  found  to  grow  almost 
b}^  magic,  should  be  curetted  away.  The  wound  is  swabbed  with 
a  10  per  cent,  solution  of  zinc  chlorid.  When  gangrene  occurs, 
in  addition  to  curetting  the  wound  the  thermocautery  should  be 
used  for  the  purpose  of  completely  destroying  the  infection  and 
sealing  the  lymph  channels.  An  efficient  dressing  consists  in 
gauze  kept  wet  with  hydrogen  peroxid.  Vaccine  therapy  is 
indicated. 

Malignant  Edema. — This  may  complicate  severe  injuries  of 
bone  and  extensive  injuries  of  the  soft  parts.  It  is  sometimes  met 
with  complicating  the  bites  of  insects.  Its  onset  is  rapid,  with 
gangrenous  edema  of  the  subcutaneous  connective  tissue  and 
intermuscular  planes.  The  overlying  skin  becomes  brownish  red, 
there  is  venostasis,  the  tissues  are  edematous,  and  on  palpation  a 
distinct  crackling  sensation  is  felt.  This  crackling  sensation  is 
due  to  the  gas  manufactured  by  the  infecting  bacillus  (Bacillus 
CEdematis  maligni).  The  discharge  from  the  wound  is  thin  and 
blood-streaked.  This  same  discharge  infiltrates  the  tissues  and 
can  be  pressed  from  them.  Lymphatic  involvement  is  rapid 
and  general  infection  soon  follows.  The  temperature  rapidly  rises 
and  remains  high.  The  mental  condition  is  blunted,  the  tongue 
is  dry,  the  pulse  rapid  and  feeble,  the  pupils  dilated.     Coma 


COMPLICATIONS    OF    WOUND    INFECTIONS  279 

supervenes,  and  death  may  occur  in  from  two  to  four  days.  The 
local  spread  of  the  disease  is  very  rapid. 

Treatment. — In  the  very  beginning  extensive  multiple  incisions 
of  the  infected  tissues,  curettage  of  the  wound  and  the  applica- 
tion of  copious  absorbent  evaporating  antiseptic  dressings  may 
be  of  avail.  A  vaccine  should  be  prepared  but  probably  will 
not  be  completed  in  time.  The  wound  should  be  inspected  every 
two  hours,  and  an  accurate  measure  kept  of  the  extent  of  the 
disease.  If  in  spite  of  these  early  measures  the  disease  spreads 
ever  so  slightly  an  amputation,  in  the  case  of  an  extremity,  should 
be  immediately  performed  as  far  above  the  disease  as  possible. 

Infectious  Emphysema. — This  complication  of  ivound  in- 
fection is  exceedingly  rare.  It  is  due  to  the  entrance  into  the 
tissues  of  the  bacillus  aerogenes  capsulatus.  Infections  by  this 
germ  spread  rapidly  and  are  accompanied  by  the  formation  of 
gas.  This  gives  a  crackling  sensation  on  palpation  of  the  tissues. 
As  a  rule,  there  is  but  slight  constitutional  disturbance. 

Treatment. — Very  mild  cases  are  met  with  which  give  only  the 
symptom  of  crepitation  in  the  neighborhood  of  the  wound. 
Should  this  show  no  disposition  to  spread,  and  be  but  slight  in 
extent,  no  treatment  will  be  necessary.  The  wound  should  be 
carefully  watched,  however,  and  if  the  infection  does  show  a 
tendency  to  spread,  the  sutures  should  be  removed,  the  wound 
curetted,  and  if  this  does  not  suffice,  multiple  incisions  made  into 
the  infected  areas  and  copious  moist  dressings  applied. 

Bacillus  Pyocyaneus  Infection. — Infections  by  this  germ  are 
characterized  by  the  peculiar  bluish-green  color  given  to  the 
wound  discharge.  As  a  rule,  infections  by  this  organism  are 
mild  and  easily  controlled.  Occasionally,  however,  it  has  been 
the  cause  of  rapidly  progressive  gangrene.^ 

This  germ  has  its  normal  habitat  in  the  skin  of  the  axilla  and 
the  groin.  Therefore  wounds  in  these  neighborhoods  are  more 
apt  to  be  infected  by  this  germ  than  wounds  elsewhere. 

The  germ  is  readily  destroyed  by  alcohol-bichlorid  solution  in 
the  proportion  of  1  :  1000  bichlorid  in  50  per  cent,  alcohol.  It  is 
readily  transmissible  in  spite  of  the  ease  with  which  it  can  be 

1  Two  cases  of  rapidly   progressive  gangrene  in   which   pure   cultures   of  the  bacillus 
pyocyaneus  were  found.     George  R,  Fowler,  N.  Y.  Medical  Journal,  February  10,  1894. 


280  OPERATING    ROOM    AND    THE    PATIENT 

destroyed  and  through   carelessness  may  be   carried  to  other 
wounds. 

Tetanus. — Fortunately  this  dread  disease  rarely  attacks 
operation  wounds.  Occasionally,  however,  cases  are  seen.  In 
these  instances  the  infection  can  in  almost  all  cases  be  traced  to 
catgut.  Kangaroo  tendon  does  not  seem  to  harbor  the  germ. 
In  one  case  which  we  have  observed  the  germ  seemed  to  have 
found  its  entrance  into  the  blood  through  the  use  of  a  potato- 
bobbin  used  in  a  gastroenterostomy.  In  another  case  the 
catgut  was  at  fault.  While  in  still  another  case  in  which  kan- 
garoo tendon  only  was  used,  the  germ  probably  was  already  in 
the  skin.  The  germ  is  found  in  thick  strands  of  catgut,  the 
interior  of  which  it  is  practically  impossible  to  sterilize.  Its 
occurrence  from  this  source  can  be  obviated  by  using  the  smaller 
sizes  of  gut.  The  time  necessary  for  the  development  of  the 
disease  depends  upon  the  amount  of  infection,  its  entrance,  the 
location  of  the  infection,  the  character  of  the  tissues  infected,  and 
the  virulence  of  the  culture.  The  usual  time  of  incubation  is 
seven  to  ten  days.  In  a  compound  fracture  coming  under  our 
care,  the  disease  developed  forty  days  following  the  receipt  of  the 
injury,  during  all  of  which  time  the  patient  was  under  our  own 
observation  in  the  hospital.  Tetanus  may  supervene  upon  an 
ordinarj"  infection  of  the  wound,  or  the  symptoms  may  not 
begin  until  wound  healing  is  apparently  complete. 

The  first  symptom  is  restlessness,  an  anxious  condition  of  the 
patient.  This  is  followed  by  difficulty  in  speaking,  next  by 
difficulty  in  swallowing,  finally  by  rigidity  of  the  neck  and  spine 
(opisthotonos).  Occasionally  emprosthotonos,  the  reverse  of 
opisthotonos,  occurs,  or  pleurosthotonos  may  occur.  The 
slightest  external  irritation,  even  a  draft  of  air,  may  bring  on  an 
aggravation  of  the  spasms.  These  cause  excruciating  pain. 
The  temperature  rises  to  104°  or  106°  F,  There  is  profuse 
sweating,  the  mental  condition  remains  unaffected,  the  pulse 
rapid  and  feeble.  The  patient  is  in  a  continual  state  of  excitation. 
The  cases  in  which  infection  has  occurred  early  in  the  course  of 
the  wound  are  almost  always  fatal.  Of  infections  occurring 
later,  some  recover.  If  the  patient  survives  the  disease  beyond 
the  fourteenth  day  recovery  is  the  rule. 


COMPLICATIONS    OF    WOUND    INFECTIONS  281 

Trismus  Associated  with  Paralysis  of  the  Facial  Nerve. — This 
is  sometimes  called  hydrophobic  tetanus  from  the  fact  that 
attempts  to  swallow  bring  on  the  spasm.  E.  Rose,  1870, 
first  described  this  disease.  It  follows  injuries  of  the  head,  and 
particularly  of  the  facial  region.  It  is  not  so  likely  to  be  fatal  as 
the  other  forms  of  tetanus.  There  may  follow  a  chronic  form 
of  the  disease  which  ends  in  death. 

Treatment. — In  wounds  from  toy  pistols,  and  in  incised  wounds 
with  laceration  of  the  deeper  structures  in  which  the  skin  itself 
rapidly  heals — i.e.,  wounds  from  which  the  air  is  excluded  (the 
tetanus  bacillus  does  not  grow  in  the  presence  of  oxygen) — an 
immunizing  dose  of  tetanus  antitoxin  should  be  administered 
proximad  to  the  wound.  In  cases  in  which  the  disease  is  al- 
ready existing,  many  forms  of  treatment  have  been  advised. 
Chloral  should  be  employed  to  diminish  the  reflex  excitability. 
Chloroform  may  be  administered  by  inhalation  to  relieve  the 
pain  and  to  relax  the  contracted  muscles.  Hypodermic  in- 
jections of  morphin  should  be  given  to  relieve  the  pain  and  de- 
crease the  irritability.  These  measures  should  be  supplemented 
by  the  use  of  tetanus  antitoxin,  the  dose  of  which  will  vary 
according  to  thei  nature  of  the  case,  the  injections  being  re- 
peated at  four-hour  intervals,  until  an  effect  on  the  spasm  is 
produced.  The  antitoxin  may  be  given  under  the  skin  in  cases 
which  are  not  extremely  urgent,  directly  into  a  vein  in  urgent 
cases.  Intracerebral  injection  in  the  frontal  lobes  has  been 
advised.  The  antitoxin  may  also  be  injected  into  the  spinal 
canal.     This  would  seem  the  most  logical  site. 

Bacelli  advises  the  injection  of  a  1  per  cent,  solution  of  carbolic 
acid,  ten  to  thirty  drops  every  three  or  four  hours. 

The  patient  should  be  nourished  by  nutrient  enemas.  When 
possible  this  should  be  supplemented  by  feeding  through  a  small 
tube  passed  through  the  nose.  The  room  should  be  darkened, 
absolute  quiet  should  be  enforced,  and  every  possible  source  of 
excitement  or  noise  avoided.  Intraspinal  injection  of  sulphate 
of  magnesia  is  efficient  in  controlling  spasm  (Blake-Meltzer). 
One  cubic  centimeter  for  each  twenty-five  pounds  of  body  weight, 
of  a  25  per  cent,  solution  is  introduced  through  lumbar  puncture. 
This  may  be  repeated.     Magnesia  sulphate  may  be  introduced 


282  OPERATING    ROOM    AND    THE    PATIENT 

into  the  cellular  tissue  using  a  sufficient  quantity  of  a  6  per  cent, 
solution  to  ensure  flacidity  of  the  muscles.  It  is  hard  to  gauge 
the  dosage  and  its  use  by  either  method  is  not  without  danger. 
Respiratory  paralysis  may  follow. 

Differential  Diagnosis. — The  clinical  picture  of  tetanus  is 
very  similar  to  that  of  strychnin  poisoning.  The  surgeon, 
however,  will  rarely  be  called  upon  to  make  this  differential 
diagnosis.  Occasionally  it  will  happen  that  in  cases  of  profound 
shock  in  which  hypodermic  injections  of  sulphate  of  strychnin 
have  been  repeatedly  employed,  and  in  which,  following  this, 
intravenous  saline  infusion  has  been  used,  there  will  result  from 
the  increased  absorption  caused  by  the  intravenous  infusion  a 
rapid  absorption  of  the  strychnin  previously  injected.  This 
rapid  absorption  may  give  rise  to  symptoms  of  strychnin  poison- 
ing. Three  such  cases  have  come  under  our  observation.  In 
such  cases  there  might  be  a  momentary  hesitation  as  to  the 
cause  of  the  spasms,  but  a  review  of  the  history  and  treatment 
of  the  case  will  speedily  reveal  the  true  condition. 


CHAPTER  X. 


COMPLICATIONS  THE  RESULT  OF  ANTISEPTICS;  COM- 
PLICATIONS THE  RESULT  OF  PRESSURE;  CIRCULA- 
TORY COMPLICATIONS. 

Wound  Disturbance  the  Result  of  Antiseptics. — Local  effect  on  wound 
surfaces.  Toxicity  of  the  antiseptic.  Individual  idiosyncrasy.  Carbolic 
acid.     Bichlorid  of  mercury.     Iodoform  poisoning.     Systemic  poisoning. 

Rashes  Occurring  in  Surgical  Patients. — General  diagnosis.  Surgical 
scarlet  fever.  Herpes.  Types  of  rash;  causation;  treatment.  Rashes  due 
to  drugs;  enemata;  ether;  sepsis. 

Complications  the  Result  of  Pressure. — ^Post-operative  paralysis.  Paralysis 
due  to  operative  traumatism.  Paralysis  of  an  entire  extremity.  Hysterical 
paralysis.  Constriction  paralysis.  Postural  paralysis.  Ischemic  muscular 
paralysis  and  contracture.     Decubitus. 

Circulatory  Complications. — Prevention  of  venous  return.  Thrombosis  of 
the  femoral  vein.  Phlebitis  of  the  internal  saphenous  vein.  Air  emboUsm. 
Fat  embolism.     Shock.     Cause  of  sudden  death  following  operation. 

WOUND  DISTURBANCES  THE  RESULT  OF  ANTISEPTICS. 

Hcwever  ideal  a  given  antiseptic  may  be  from  a  bacteriologic 
standpoint,  it  is  upon  the  practical  results  following  its  clinical 


COMPLICATIONS    THE    RESULT    OF    ANTISEPTICS  283 

employment  that  our  judgment  of  it  must  be  based.  The 
value  of  an  antiseptic  depends,  first,  upon  its  power  of  destroying 
or  inhibiting  the  growth  of  germs;  second,  upon  its  local  effect 
on  the  wound,  whether  neutral,  irritating,  or  caustic;  and, 
third,  upon  the  ease  with  which  it  may  be  absorbed  and  the 
toxicity  of  such  absorption. 

Sternberg  demonstrated  that  bacterial  death  was  produced 
by  bichlorid  of  mercury  in  1:20,000  solution;  iodin  in  1:500; 
potassium  permanganate  in  1 :  338;  carbolic  acid  in  1 :  100.  These 
strengths  were  sufficient  to  destroy  pus  cocci  in  two  hours,  and 
were  also  efficient  in  the  case  of  other  microorganisms.  Their 
inhibiting  power  was  found  to  be:  Bichlorid  of  mercury,  1 : 30,000; 
iodin,  1:4000;  carbolic  acid,  1:500;  boracic  acid,  1:200;  alcohol, 
1: 10.  Further  bacterial  researches  have  shown  that  still  smaller 
proportions  of  the  first  three  mentioned  are  sufficient  to  inhibit 
bacterial  growth.  In  wounds  the  germs  are  not  all  on  the 
surface  alone,  where  they  come  into  intimate  relationship  with 
the  antiseptic  used,  but  reside  deeper  in  the  tissues,  so  that  the 
power  of  penetration  of  the  antiseptic  into  the  tissues  must 
enter  into  the  calculation.  It  is  also  to  be  borne  in  mind  that 
even  strong  antiseptics  do  not  necessarily  kill  germs,  but  may 
only  inhibit  their  growth,  so  that  if  they  are  freed  from  the 
antiseptic  they  may  continue  to  multiply.  The  inhibiting 
power  of  the  antiseptic  used  may  be  neutralized  by  the  albumin- 
ous secretion  of  the  wound  and  germ  growth  proceed.  The 
above  shows  the  desirability  of  the  prevention  of  infection  by  all 
possible  means,  since  the  actual,  positive  destruction  of  the 
germ  is  impossible  with  the  use  of  antiseptics  in  strengths 
which  will  not  of  themselves  cause  actual  destruction  of  tissue. 

Certain  antiseptics  in  a  dry  form  are  of  value:  Iodoform, 
naphthalin,  zinc  oxid,  and  the  various  preparations  of  bismuth. 
Newer  antiseptics  possess  no  great  advantages  over  the  older 
preparations.  Zinc  oxid  is  the  best  of  the  above,  as  it  produces 
marked  chemotaxis,  as  does  also  naphthalin.  These  powders 
have  the  property  of  absorbing  or  combining  with  wound 
secretions. 

Local  Effect  on  Wound  Surfaces. — Strong  antiseptics  cannot 
be  used  in  wound  treatment  except  in  those  cases  in  which 


284  OPERATING    ROOM    AND    THE    PATIENT 

actual  destruction  of  the  superficial  layer  of  the  wound  is  desired. 
In  wounds  infected  by  the  common  pus  organisms  this  is  not 
desirable,  as  the  dead  tissue  forms  a  nidus  for  the  further  growth 
of  germs.  In  infections  the  result  of  anthrax,  actinomycosis,  or 
chancroidal  infection,-  stronger  antiseptics  or,  better,  the  actual 
cautery  are  to  be  used  to  destroy  the  germs,  and  in  order  to 
thoroughly  destroy  them  it  will  be  necessary  to  destroy  a  portion 
of  the  adjacent  tissue  as  well.  These  agents  are  stronger  on 
account  of  their  great  caustic  action.  Nitric  acid,  chlorid  of 
zinc,  and  potassa  fusa  are  the  most  prominent.  They  act  by  an 
actual  destruction  of  tissue.  Their  use  has  become  more  and 
more  restricted,  the  thermocautery  taking  their  place  as  a  more 
reliable  method  of  destruction  and  as  being  more  completely 
under  the  control  of  the  operator.  Zinc  chlorid  finds  a  field  of 
usefulness  in  the  treatment  of  inoperable  carcinoma  of  the  uterus 
with  involvement  of  the  cervix,  and  in  treating  gangrenous 
areas. 

Flushing  with  weak  solutions  of  antiseptics  tends  to  stimulate 
leucocytosis,  as  well  as  mechanically  wash  away  or  inhibit  the 
growth  of  germs,  and  hence  is  advantageous  even  in  the  first 
stages  of  wound  infection.  On  the  other  hand,  though  strong 
solutions  produce  leucocytosis,  this  is  accompanied  by  actual 
destruction  of  tissue  and  an  escharing  of  the  tissues  which  not 
only  serves  as  a  nidus  for  germ  growth,  but  mechanically  pre- 
vents the  escape  of  germs  from  the  tissue,  and  hence  is  not  to  be 
practised  in  the  treatment  of  ordinary  infected  wounds.  One 
of  the  chief  points  to  be  remembered  in  the  treatment  of  infected 
wounds  is  that  a  free  exit  must  be  provided  for  all  wound  secre- 
tion. Nature  will,  as  a  rule,  take  care  of  those  germs  already 
in  the  tissues  if. the  wound  is  kept  free  from  accumulated  infec- 
tion. More  active  measures  may  be  harmful  in  that  at  the  very 
least  they  retard  the  healing  process. 

Toxicity  of  the  Antiseptic. — In  general,  it  may  be  stated 
that  large  quantities  of  antiseptic  are  harmful  and  may  produce 
general  toxic  effects.  Weak  solutions  are  more  apt  to  be  ab- 
sorbed than  strong  solutions,  as  the  stronger  the  solution  the 
more  active  the  local  leucocjrtosis  produced.  Particularly  is 
this  true  of  carbolic  acid.     The  area  of  the  absorbing  surface, 


COMPLICATIONS    THE    RESULT    OF    ANTISEPTICS  285 

whether  flat,  a  cavity,  or  a  sinus,  as  well  as  the  length  of  time 
the  solution  is  applied,  must  also  be  considered. 

Individual  Idiosyncrasy. — In  certain  individuals  a  form  of 
eczema  is  quickly  set  up  by  the  application  of  even  a  weak 
solution  of  bichlorid  of  mercury,  carbolic  acid,  or  iodin.  Iodo- 
form is  particularly  prone  to  produce  undesirable  local  effects. 
It  is  impossible  to  prognosticate  those  cases  which  will  be  so 
unfortunate  as  to  become  either  locally  or  generally  poisoned. 
The  skin  of  children  and  old  persons  is  more  delicate  than  that  of 
more  robust  persons,  and  they  are  consequently  more  readily 
susceptible. 

Carbolic  Acid. — This  agent  was  first  introduced  by  Lemaire 
in  1863,  but  it  was  not  until  Lister  in  1866  formulated  an  elabo- 
rate system  of  disinfection  and  dressing  that  its  usefulness  was 
generally  recognized.  It  is  today  one  of  the  best  known  anti- 
septics, but  its  disadvantages  are  so  marked  that  its  field  of 
'usefulness  has  been  greatly  narrowed.  Its  advantage  consists 
in  the  reliability  with  which  it  destroys  (1:20  to  1:40),  renders 
inert  (1: 100  to  1:500),  septic  microorganisms,  and  the  readiness 
with  which  it  mixes  with  wound  secretions.  Weak  solutions 
produce  no  coagulation  and  penetrate  to  all  parts  of  the  wound. 
On  the  other  hand,  its  disadvantages  outweigh  in  most  cases  its 
advantages.  Its  volatility  necessitates  frequent  change  of 
dressing.  If  this  is  guarded  against  by  placing  rubber  protect- 
ive, oiled  silk,  or  a  similar  air-tight  material  over  the  dressing, 
local  heat  is  retained  and  the  dressing  becomes  a  poultice,  favor- 
ing wound  secretion.  The  parts  become  sodden,  the  superficial 
layers  of  the  skin  exfoliate,  and  a  condition  is  produced  which 
greatly  favors  germ  growth — i.e.,  heat,  moisture,  and  a  culture- 
medium.  The  skin  is  rapidly  reduced  to  a  condition  of  moist 
eczema,  and  if  the  treatment  be  persevered  in,  gangrene  may 
develop.  Following  its  prolonged  use  the  part  becomes  first 
moist,  then  anesthetic.  Local  anemia  is  marked.  The  skin 
becomes  dirty  gray  in  color,  and  dry  gangrene  ensues,  which 
may  involve  all  the  tissues  of  the  part,  even  the  bone.  In  mild 
cases  the  gangrene  does  not  extend  beneath  the  skin.  In  severe 
cases  amputation  will  be  necessary.  These  results  are  more 
frequent  in  the  fingers  and  toes.     The  simplest  cases  will  have 


286  OPERATIXG  EOOM  AND  THE  PATIENT 

intense  burning  at  first  and  the  skin  will  present  a  blistered 
appearance.  If  the  drug  is  discontinued  at  this  stage,  no  danger 
is  to  be  apprehended.  Severe  as  are  its  local  toxic  effects,  the 
results  of  absorption  are  to  be  borne  well  in  mind.  The  persons 
who  seem  to  be  particularly  susceptible  to  poisoning  are  young 
children  and  old  people,  and  patients  suffering  from  renal  disease. 
Large  fresh  wounds  absorb  the  acid  rapidly.  Its  rapid  absorp- 
tion in  large  quantities  is  marked  by  profound  collapse,  and  death 
shortly  ensues  through  failure  of  respiration.  Slower  absorption 
is  marked  by  severe  gastric  sj^mptoms,  nausea,  and  protracted 
vomiting.  Giddiness,  stupor,  and  aural  vertigo  develop.  The 
pulse  is  small  and  rapid.  The  quantity  of  urine  is  decreased  and 
is  colored  gTeen.  The  discoloration  is  apparent  after  the  urine 
has  been  exposed  for  some  time  to  light.  The  sulphates  are 
absent  from  the  urine.  The  treatment  consists  in  abandoning 
the  use  of  the  antiseptic,  washing  the  wound  thoroughly  with 
alcohol  to  neutralize  the  carbolic  acid  and  prevent  further 
absorption,  and  the  ingestion  of  large  quantities  of  alcohol  in 
the  form  of  brandy.  The  bladder  should  be  catheterized  fre- 
quently to  prevent  absorption  through  its  wall  of  the  acid  in  the 
urine.  Intravenous  infusion  will  raise  the  blood-pressure,  and 
by  thus  increasing  the  functional  activity  of  the  kidneys,  effect 
more  rapid  elimination  of  the  poison.  Atropin  should  be  given 
for  its  effect  upon  the  respiration.  Oxygen  will  assist  materially. 
Sodium  sulphate  has  been  advised. 

Unfortunately  individual  idiosyncrasy  plays  an  important 
role.  The  injection  of  a  small  quantity  of  a  weak  solution  into 
a  narrow  sinus  may  cause  alarming  symptoms.  It  is  absolutely 
impossible  to  forecast  the  result  of  the  poison  in  individual  cases. 
The  escharing  effect  of  the  pure  acid  renders  its  use  safer  than 
dilute  solutions,  its  poisonous  effect  being  expended  upon  the  tissue 
with  which  it  comes  in  contact.  The  cases  which  are  more  likely 
to  result  in  local  gangrene  are  those  in  which  moderate^  strong 
solutions  are  applied  to  a  part  and  the  acid  prevented  from 
volatilizing  by  an  air-tight  covering. 

At  the  present  time  the  use  of  this  antiseptic  is  limited  to  the 
primary  disinfections  of  long  existing  or  well  isolated  abscess 
cavities,  in  those  around  which  nature  has  thrown  a  protective 


COMPLICATIONS    THE    RESULT    OF    ANTISEPTICS  287 

zone,  and  only  in  those  cases  in  which  the  action  of  the  acid  can 
be  observed.  Acid  of  95  per  cent,  strength  is  poured  into  the 
wound  cavity,  the  surrounding  parts  being  protected  with  gauze 
wrung  out  of  absolute  alcohol.  The  acid  is  allowed  to  remain 
in  contact  with  the  wound  one  minute,  during  which  time  it 
penetrates  to  all  parts  of  the  wound.  It  is  then  washed  away 
with  absolute  alcohol.  In  the  treatment  of  obstinate  sinuses  of 
moderate  extent,  equal  parts  of  iodin  and  carbolic  acid  may  be 
injected,  but  the  sinus  must  be  subsequently  washed  out  with 
alcohol.  Furuncles  in  the  primary  stage  may  be  injected  with 
one  or  two  minims  of  the  pure  acid,  and  after  two  minutes 
have  elapsed  an  equal  quantity  of  absolute  alcohol  may  be  in- 
jected. The  use  of  carbolic  acid  as  a  wound  dressing  has  become 
almost  entirely  superseded  in  our  work  by  an  acid  alcohol- 
bichlorid  solution.  Certain  other  coal-tar  products  have  been 
brought  forward  to  replace  carbolic  acid,  such  as  creolin  and 
lysol.  They  are  more  expensive  and  their  advantages  are  not 
sufficient  to  warrant  their  use  over  that  of  an  acid  alcohol- 
bichlorid  solution. 

Bichlorid  of  Mercury. — When  first  recommended  as  a  trust- 
worthy antiseptic  in  the  treatment  of  wounds  by  Koch  in  1881, 
this  drug  was  extensively  used.  Gradually  its  field  of  usefulness 
had  become  narrowed,  both  on  account  of  the  local  necrosing 
effect  common  to  antiseptics  and  on  account  of  its  toxic  effects, 
both  local  and  general.  At  the  present  time  its  use  is  limited 
to  disinfection  of  the  skin  in  strengths  of  from  1 :  1000  to  1 :  4000 
and  to  disinfection  of  wounds  in  which  the  infection  has  been 
recent  or  is  presumed  to  have  occurred,  but  in  which  the  local 
evidences  of  inflammation  are  slight.  Combined  with  50  per 
cent,  alcohol,  however,  it  is  of  considerable  Use  as  a  wet  dressing 
in  cases  of  long-continued  suppuration  and  in  recently  opened 
infections,  such  as  felons  and  abscesses.  It  is  employed  in  cases 
in  which  carbolic  acid  was  formerly  used.  It  rarely  produces 
constitutional  effects.  With  this,  as  with  other  antiseptics, 
local  irritation  may  be  set  up  if  strong  solutions  are  employed  or 
if  free  evaporation  is  prevented.  In  cases  in  which  its  use  is 
long  continued,  or  when  a  large  wound  surface  has  rapidly 
absorbed  a  quantity  of  the  bichlorid  solution,  typical  symptoms 


288  OPERATING    ROOM    AND    THE    PATIENT 

of  poisoning,  with  salivation,  loss  of  appetite,  vomiting,  abdom- 
inal cramps,  albuminuria,  and  bloody  diarrhea  will  develop 
and  death  may  ensue.  The  treatment  is  to  discontinue  the  drug, 
stimulate  the  patient,  give  warm  baths,  and  treat  the  gastro- 
enteritis. A  1  per  cent,  solution  applied  to  a  large  surface  has 
been  known  to  produce  fatal  poisoning. 

lodofonn  Poisoning. — The  local  effects  are  irritation  and  red- 
ness and  a  wet,  eczematous  condition  of  the  surrounding  skin. 
The  redness  spreads  beyond  the  dressing  and  the  skin  becomes 
swollen.  Blebs  form,  which  somewhat  resemble  erysipelas 
bullosum.  These  blebs  vary  in  size  from  a  pin  head  to  a  small 
marble.  The  absence  of  fever  differentiates  it  from  erysipelas. 
A  general  erythema  may  appear.  The  treatment  is  to  stop  the 
drug  and  apply  1  or  2  per  cent,  silver  nitrate  to  the  inflamed 
surfaces. 

Systemic  'poisoning  following  the  use  of  iodoform,  either  as 
a  wound  dressing  or  as  an  injection  in  tuberculous  cavities  or 
sinuses,  is  fortunately  not  common.  Such  poisoning  is  more'dan- 
gerous  than  that  following  the  use  of  other  antiseptics  because 
more  insidious.  Idiosyncrasy  must  be  taken  into  account.  Chil- 
dren seem  more  susceptible  than  adults.  Fatal  intoxication  may 
result  from  a  very  small  amount.  Great  care  should  be  exercised 
in  using  this  drug  in  the  neighborhood  of  the  kidney.  The  general 
symptoms  are  caused  by  the  decomposition  of  the  iodoform. 
There  occurs  slight  rise  of  temperature,  the  pulse-rate  rapidly 
increases  in  frequency.  In  the  early  stages  there  is  headache,  a 
feeling  of  lassitude  and  depression,  vomiting,  loss  of  appetite, 
and  anuria.  Then  occurs  restlessness,  hallucinations,  and  delir- 
ium. The  symptoms  may  persist  with  more  or  less  severity  for 
an  almost  indefinite  period.  In  the  acute  form'  death  rapidly 
ensues.  The  autopsy  will  show  fatty  degeneration  of  the  heart 
muscle  and  of  the  kidneys  and  liver. 

There  are  certain  conditions  which  predispose  to  iodoform 
poisoning.  Fats  dissolve  iodoform,  so  absorption  occurs  more 
readily  in  large  wounds  of  the  fatty  subcutaneous  tissue,  to  a 
lesser  extent  in  other  tissues.  Iodoform  in  powder  form  is  more 
readily  absorbed  than  when  incorporated  in  gauze.     The  perito- 


COMPLICATIONS    THE    RESULT    OF    ANTISEPTICS  289 

neum  absorbs  the  drug  readily,  as  it  does  all  soluble  foreign  matter 
brought  in  contact  with  it. 

It  should  be  used  with  care  in  children  and  old  persons  with 
weakened  heart  muscle.  In  cases  suffering  from  kidney  lesions 
it  should  not  be  used  at  all.  In  cases  of  severe  anemia  it  is 
dangerous. 

Treatment  consists  in  thoroughly  cleansing  the  wound  surfaces 
of  the  drug.  Curetting  should  be  done  when  the  powder  has 
been  used.  Large  quantities  of  water  should  be  given;  also 
vegetable  alkalies,  stimulation,  saline  infusion,  and  saline  enemas 
should  be  employed.  Bicarbonate  of  potash  in  solution  is  recom- 
mended as  an  antidote,  both  internally  and  as  a  wash  for  the 
wound. 

Picric  Acid  Poisoning. — This  may  follow  the  use  of  picric  acid 
in  the  treatment  of  burns.  Its  occurrence  is  rare  and  death  has 
not  been  traced  to  its  use.  The  symptoms  are  nausea,  vomiting, 
headache  and  an  intense  yellow  color  of  the  skin  and  mucous 
membranes.  The  acid  is  excreted  by  the  kidneys  and  the  urine 
will  be  yellow,  brown  or  black.  Jaundice  is  excluded  by  the 
presence  of  bile  in  the  stools. 

Treatment. — Change  to  dressing  of  another  character  causes 
disappearance  of  the  symptoms.  The  yellow  discoloration  of 
the  skin  due  to  deposit  of  the  pigment  fades  away  gradually. 

RASHES  OCCURRING  IN  SURGICAL  PATIENTS. 

General  Diagnosis  of  Rashes. — When  a  rash  appears  in  a  post- 
operative case  the  time  of  its  occurrence,  the  medication  used  in 
the  case,  the  form  of  enemata,  the  character  of  the  operation  and 
all  other  points  in  connection  with  the  same  must  be  carefully 
considered.  Rashes  are  not  very  common  but  when  they  do 
occur  are  apt  to  cause  a  great  deal  of  anxiety  to  the  patient  and 
if  a  diagnosis  cannot  be  speedily  reached  as  to  the  cause,  con- 
siderable anxiety  to  the  surgeon.  Operative  patients  are  no  less 
liable  to  general  infectious  diseases  than  are  other  persons.  In 
fact  to  some  diseases  they  are  more  liable  owing  to  their  lowered 
vital  resistance.  The  particular  disease  which  it  is  essential  to 
exclude  is  scarlet  fever  and  this  may  be  excluded  from  rashes 
caused  by  other  diseases  by  the  appearance  of  the  throat  and 

19 


290  OPERATING    ROOM    AND    THE    PATIENT 

tongue.  If  any  doubt  exists  as  to  the  character  of  the  rash  the 
patient  should  be  isolated  until  a  decision  is  arrived  at.  Particu- 
larly in  the  children's  department  of  a  hospital  is  care  to  be 
used  in  differentiating. 

Surgical  Scarlet  Fever. — According  to  McCoUom^  the  existence 
of  surgical  scarlet  fever  in  distinction  from  medical  scarlet  fever 
is  a  disputed  point.  Patients  on  whom  a  surgical  operation  has 
been  performed  if  exposed  to  scarlet  fever  are,  no  doubt,  more 
likely  to  contract  the  disease  by  reason  of  their  lessened  resisting 
power.  Many  rashes  occurring  in  surgical  patients  caused  by 
drugs  are  mistaken  for  scarlet  fever  rashes  and  in  former  days 
before  the  era  of  aseptic  surgery  septic  rashes  were  commonly 
confused  with  scarlet  fever. 

Patients  suffering  from  burns  are  apt  to  contract  scarlet  fever 
more  readily  than  would  be  the  case  if  the  skin  were  intact. 
Scarlet  fever  in  surgical  patients  is  to  be  regarded  for  the  most 
part  as  coincident. 

Herpes. — An  attack  of  herpes  may  follow  an  operation  upon 
the  genito-urinary  organs.     Its  occurrence  is  probably  coincident. 

Types  of  Rash. — Martin^  cites  four  types  of  surgical  rashes: 
(1)  typical  urticaria,  raised  wheals  with  white  crests  and  red 
bases;  (2)  small  red  raised  papules  the  size  of  mustard  seeds  with  a 
pale  pink  field  between;  (3)  irregular  dusky  red  blotches  not  un- 
like measles;  (4)  a  uniform  vivid  scarlet  blush  resembling  that  of 
scarlatina.  The  favorite  sites  for  the  rash  are  the  extensor 
surfaces  of  the  elbows,  forearms,  hands,  and  knees,  the  face  and 
front  of  the  chest.  The  rash  may  suddenly  leave  one  area  and 
invade  a  distant  one.  The  duration  is  from  one  to  four  days; 
as  it  is  fading  the  skin  affected  may  present  a  yellow  tinge. 
Occasionally  there  are  constitutional  symptoms  resembling  mild 
scarlatina.  If  the  rash  has  been  very  marked  desquamation 
follows. 

Causation. — Rashes  occur  in  post-operative  patients  just  as 
they  occur  in  other  individuals.  The  rash  may  be  produced  by 
certain  articles  of  diet,  certain  drugs,  or  the  cause  may  not  be 
asertainable.     Some  patients  acquire  rashes  after  the  administra- 

'  Osier's  Modern  Medicine,  1907,  vol.  ii,  p.  359. 

^  The  after-treatment  of  Abdominal  Section,  London,  1894. 


COMPLICATIONS    THE    RESULT    OF    ANTISEPTICS  291 

tion  of  a  turpentine  enema.  With  aseptic  conditions  of  the 
wound  L.  rash  may  develop.  Martin  cites  four  cases  occupying 
consecutively  the  same  bed  in  all  of  whom  an  eruption  occurred 
post-operatively.  As  a  rule  they  occur  in  patients  who  other- 
wise present  no  other  untoward  symptoms. 

Treatment. — The  cause  should  be  ascertained  and  removed. 
Other  than  the  removal  and  the  treatment  of  the  cause,  the  only 
treatment  indicated  is  saline  purgation. 

Rashes  due  to  Drugs. — Many  of  the  drugs  commonly  used 
in  post-operative  treatment  are  capable  of  setting  up  a  punctate 
erythema  which  has  frequently  been  difficult  to  differentiate 
from  that  of  scarlet  fever.  The  points  in  differential  diagnosis 
are  the  absence  of  the  characteristic  appearance  of  the  mucous 
membrane  in  the  throat,  the  appearance  of  the  papillae  on  the 
tongue  and  the  variety  of  constitutional  disturbance.  Bichlorid 
of  mercury  will  in  some  cases  produce  a  punctate  erythema 
twenty-four  hours  after  its  application  in  the  preparation  for  an 
operation.  Iodoform  in  individuals  susceptible  to  it  will  cause  an 
eruption  similar  to  that  of  scarlet  fever.  Copaiba  may  cause  a 
rash  similar  to  that  of  scarlet  fever,  though  the  rash  more  fre- 
quently resembles  measles.  Strychnine  sometimes,  though  rarely, 
produces  a  rash  resembling  scarlet  fever.  An  eruption  caused  by 
ofropin  has  been  mistaken  for  scarlet  fever,  Quinin  in  persons 
having  an  idiosyncrasy,  will  cause  a  general  punctate  eruption 
very  closely  resembling  scarlet  fever.  It  may  then  be  followed 
by  desquamation.  Salicylic  acid  locally  may  produce  small  clear 
vesicles,  the  bases  of  which  may  be  inflamed.  It  is  not  accom- 
panied by  itching  and  rapidly  disappears  if  the  character  of  the 
dressing  is  changed.  The  rash  appears  on  those  parts  of  the  skin 
with  which  the  salicylic  acid  has  come  in  contact. 

Other  drugs  which  may  cause  rashes  are  bromids,  chloral, 
belladonna,  the  coal-tar  products,  the  iodids,  opium  and  its 
derivatives,  sodium  benzoate  and  chlorid  of  potash. 

Rashes  following  Enemata. — Such  rashes  have  been  noted 
after  soap  enemata,  especially  if  hard  soap  has  been  used,  or 
turpentine  enemata.  It  is  probably  due  to  absorption  of  a 
portion  of  the  enema.  It  is  not  very  common  after  enemata  in 
which  soft  soap  has  been  used,   or  after  small  as  after  large 


292  ■     OPERATIXG    EOOM    AXD    THE    PATIENT 

enemata.  It  appears  within  twenty-four  hours  following  the 
enema.  The  usual  type  resembles  scarlet  fever,  measles  or 
urticaria,  or  a  combination  of  these  forms  may  be  observed. 
Itching  may  accompany  any  of  the  forms.  Severe  itching 
accompanies  the  urticarial  variety.  As  the  rash  is  rarely  severe 
desquamation  is  not  common.  Fever  is  absent  as  a  rule  but  a 
slight  elevation  of  temperature  may  occur.  Occasionally  nausea 
and  vomiting  accompany  the  onset  of  the  rash.  The  duration  of 
the  rash  is  two  to  four  days.     It  fades  away  slowly. 

Treatment. — Irritating  substances  should  be  excluded  from 
future  enemata  in  susceptible  cases  as  a  reappearance  of  the 
rash  is  possible.  '  Severe  itching  is  relieved  by  bathing  with 
sodium  bicarbonate  solution.     General  treatment  is  unnecessary. 

Ether  Rash. — At  the  height  of  ether  anesthesia,  usually  in 
females,  bright  red  blotches  ma}'  appear  suddenly  on  the  face 
and  neck.  These  are  without  clinical  significance.  The  blotches 
appear  in  the  areas  supplied  by  the  superficial  cervical  plexus, 
are  large,  irregular,  sharply  defined,  and  irregularly  situated. 
They  are  analagous  to  the  nervous  blotches  appearing  during 
periods  of  excitement  from  any  cause. 

Septic  Rash. — Various  forms  of  rash  accompany  septic  con- 
ditions and  form  part  of  the  picture  in  general  sepsis.  The 
onset  of  the  rash  is  usually  accompanied  by  some  rise  in  tem- 
perature, symptoms  of  general  malaise  and  rapid  pulse.  The 
rash  may  be  as  bright  as  the  scarlet  erythema  of  scarlet  fever; 
there  may  be  a  uniform  injection  of  the  skin;  it  may  be  punctate 
or  blotchy;  more  rarely  papular.  The  eruption  may  fade  on 
pressure.  It  is  varied,  the  most  common  type  a  uniform  scarlet 
rash  appearing  simultaneously  all  over  the  body.  In  other 
cases  it  may  be  confined  to  the  buttock  and  flexor  aspects  of  the 
thighs  and  skin  over  the  extremities,  or  on  the  ankles,  hands  or 
wrists.  The  rash  may  last  a  few  days  and  then  fade  away. 
Occasionally  it  persists  for  a  week  or  even  longer.  Desciuamation 
follows  in  the  more  severe  forms.  Temporary  albuminuria  is 
present  in  the  more  severe  cases.  The  general  appearance  of  the 
patient  is  that  of  a  var3ang  degree  of  sepsis.  A  few  days  after 
the  clearing  up  of  the  septic  condition  the  rash  clears  up. 

The  occurrence  of  the  rash  depends  upon  the  susceptibility  of 


COMPLICATIONS    THE    RESULT    OF    ANTISEPTICS  293 

the  patient  to  infection;  it  is  more  frequently  seen  in  children  than 
in  adults  and  in  some  cases  is  the  only  evidence  of  sepsis  present. 
The  wound  may  present  very  slight  evidence  of  sepsis  but 
the  rash  itself  is  an  evidence  of  general  infection.  The  treatment 
is  the  treatment  of  septicemia. 

COMPLICATIONS  THE  RESULT  OF  PRESSURE. 

Post-Operative  Paralysis. — The  occurrence  of  post-operative 
paralysis  may  be  discovered  while  the  patient  is  recovering 
consciousness  from  the  anesthetic,  at  which  time  it  is  noted  that 
the  patient  fails  to  move  the  part  affected.  More  commonly, 
however,  the  discovery  is  made  at  a  later  time,  when  the  patient 
complains  of  inability  to  move  the  affected  part.  In  case  the 
paralysis  affects  a  part  of  the  body  covered  by  a  dressing  the 
discovery  may  only  be  made  when  the  dressing  is  changed. 

Paralysis  Due  to  Operative  Traumatism. — The  cause  may  be 
in  the  operative  procedure  itself,  particularly  if  the  operation 
has  been  in  the  neighborhood  of  or  has  involved  one  or  more 
large  nerve  trunks.  The  suspicion  would  naturally  arise,  in 
such  a  case,  that  the  nerve  or  nerves  had  been  cut,  ligated, 
contused  through  retraction,  perhaps  pressed  upon  by  a 
drainage  strip,  or  even  injured  by  the  antiseptic  employed.  The 
prognosis  will  depend  greatly  upon  the  rapidity  with  which 
'symptoms  of  improvement  appear.  Should  symptoms  of 
return  of  function  appear  after  a  few  days  or  weeks,  a  rapid 
recovery  may  be  looked  for;  if  after  several  months,  recovery 
will  be  slow;  if  a  longer  period  elapses  without  definite  symptoms 
of  return  of  function,  recovery  may  be  despaired  of.  In  this 
particular  class  of  cases  it  is  almost  always  a  single  nerve  that  is 
affected;  for  example,  the  recurrent  laryngeal  nerve  in  goiter 
operations,  and  the  ulnar  nerve  in  elbow-joint  resections. 

It  is  rarely  that  the  exigencies  of  an  operation  will  demand 
destruction  of  an  important  nerve  structure.  If  such  is  necessi- 
tated by  the  operation,  the  nerve  should  be  united  whenever 
such  a  course  is  practical.  The  inclusion  of  a  nerve  in  a  ligature 
is  inexcusable.  Sufficient  retraction  must  be  employed  to 
clearly  expose  the  operative  field,  but  never  to  the  extent  of 
injuring  the  underlying  tissues. 


294  OPERATING    ROOM    AND    THE    PATIENT 

Paralysis  of  an  Entire  Extremity. — It  sometimes  happens 
that  an  entire  extremit}'  is  affected;  for  example,  after  resection 
of  the  elbow  there  may  be  found  total  paralysis  of  the  forearm 
extending  up  to  but  not  beyond  the  level  of  the  operation.  It 
hardly  seems  probable  that  the  musculo-spiral,  median,  and 
ulnar  could  all  have  received  operative  injury.  It  may  be  that 
such  cases  are  hysterical.  If  so,  there  should  be  other  signs  of 
hysteria  present.  In  addition,  hysterical  paralysis  may  occur 
in  any  part  of  the  body  other  than  that  operated  upon.  True 
hysterical  paralysis  occurs  in  patients  having  a  hereditary 
predisposition  to  mental  disturbances.  Some  have  post- 
operative amnesia,  others  delirium  or  mental  confusion.  They 
may  resemble  hysterotraumatic  palsies.  That  such  cases  are 
hysterical  in  origin  is  further  shown  by  the  fact  that  such  dis- 
turbances do  not  occur  in  children,  and  also  that  they  are  not 
observed  among  soldiers.  This  latter  is  probably  due  to  the 
care  exercised  in  the  selection  of  soldiers. 

Constriction  Paralysis. — The  tourniquet  is  responsible  for 
some  paralyses,  though  fortunately  this  cause  is  rare  and  can 
always  be  avoided.  The  most  common  example  is  paralysis  of 
the  musculo-spiral  nerve.  As  a  result  of  carelessness  or  igno- 
rance, the  tourniquet,  instead  of  being  applied  at  a  higher  level, 
may  be  placed  around  the  arm  at  the  point  where  this  nerve 
curves  around  the  humenis.  Constriction  paralyses  are  more 
apt  to  occur  in  lean  individuals. 

Postural  Paralysis. — This  is  caused  by  faulty  position  of  the 
patient  on  the  table.  The  nerves  affected  may  be  at  a  distance 
from  the  field  of  operation.  For  example,  a  laparotomy  case 
may  develop  paralysis  involving  part  or  all  of  the  brachial  plexus, 
or  a  paralj^sis  of  the  ulnar  or  musculo-spinal  nerve.  In  paralysis 
involving  the  brachial  plexus  the  cause  resides  in  a  faulty  position 
of  the  arms  above  the  head.  The  arms  are  stretched  forcibly 
above  the  head,  instead  of  being  placed  in  a  natural  position. 
Not  only  are  the  nerves  put  on  the  stretch,  but  the  position  of 
the  arm  causes  the  head  of  the  humerus  to  press  on  the  brachial 
plexus,  which  may  be  further  pressed  upon  by  the  clavicle. 

When  the  ulnar  nerve  is  affected  it  will  be  the  result  of  a 
faulty  fixation  of  the  arm  across  the  chest.     If  the  arms  are  too 


COMPLICATIONS    THE    RESULT    OF    ANTISEPTICS  295 

tightly  fastened  respiration  is  interfered  with;  if  insecurely 
fastened  the  arms  will  fall  down  beside  the  chest  and  are  apt  to 
rest  against  the  edge  of  the  table  in  the  neighborhood  of  the  ulnar 
nerve.  In  the  case  of  the  musculo-spiral  nerve  the  pressure  of 
an  assistant  leaning  against  the  patient,  the  arm  being  fastened 
across  the  chest,  has  been  known  to  cause  paralysis. 

Other  examples  of  paralysis  of  the  upper  extremity  are  seen 
in  improper  Sims'  position  by  not  guarding  the  underlying  arm 
against  pressure;  pressure  on  the  shoulder  by  not  having  the 
shoulder  crutch  used  in  the  Trendelenburg  position  well 
padded. 

In  the  case  of  the  lower  extremity,  paralysis  may  result  from 
pressure  or  stretching  in  an  improper  Trendelenburg  position 
the  patient's  legs  being  flexed  at  the  knees  and  supporting  the 
entire  weight  of  the  body.  Stretching  of  the  sciatic  nerve  may 
result  from  a  too  exaggerated  lithotomy  position  or  the  lithotomy 
posts  may  press  too  forcibly  against  the  limbs,  or  an  assistant 
may  lean  against  the  leg  of  a  patient  in  the  lithotomy 
position. 

In  these  paralyses  sensation  is  disturbed,  but  slightly  and 
quickly  returns. 

Paralysis  the  result  of  nerve  stretching  or  nerve  pressure 
from  improper  position  of  the  patient,  need  only  be  borne  in 
mind  to  be  avoided.  Parts  of  the  body  where  paralysis  is  readily 
produced  should  be  protected  from  pressure.  Positions  demand- 
ing extraordinary  strain  should  be  avoided.  The  assistant 
should  never  rest  against  the  patient.  Even  slight  continued 
pressure  on  a  patient's  chest  will  produce  difficulty  of  respiration. 

It  is  fortunately  true  that,  while  serious  paralyses  do  occur, 
they  are  rare.  More  often  there  is  present  a  weakness  or  paresis 
of  the  affected  part.  This  is  transitory  and  easily  overlooked. 
The  patient  mistakes  the  feeling  of  weakness  for  a  natural  out- 
come of  the  operation,  and  at  first  does  not  call  attention  to  it. 
This  will  be  particularly  the  case  if  the  affected  part  is  covered 
with  a  dressing. 

These  paralyses  or  pareses  may  be  caused  by  pressure  from 
dressings  upon  a  nerve.  As  a  rule,  this  is  because  the  splint 
has  been  improperly  applied,  though  it  may  follow  secondary 


296  OPERATING  ROOM  AND  THE  PATIENT 

s^^'elling  under  the  dressing.  For  example,  the  external  popliteal 
nerve  at  the  point  where  it  goes  around  the  fibula  may  be  pressed 
upon  by  dressings  for  fracture  of  the  leg. 

The  necessity  for  using  every  care  and  precaution  to  guard 
against  such  accidents  is  apparent,  but  even  more  necessarj^  is 
their  early  recognition  when  the}'  do  occur.  The  longer  the 
conditions  causing  them  are  allowed  to  persist,  the  more  lasting 
will  be  the  paralyses.  If  for  no  other  reason,  dressings  should  be 
inspected  and  the  condition  of  the  parts  noted  at  sufficiently 
frequent  intervals  to  guard  against  such  calamities.  This  is 
particularly  true  in  cases  in  which  such  disturbances  are  likely 
to  occur.  The  earlier  the  condition  is  noticed,  the  more  rapidly, 
safely,  and  easily  can  a  normal  condition  be  brought  about  by 
an  immediate  removal  of  the  cause  and  the  administration  of 
galvanism,  faradism  and  massage  to  the  affected  member. 

Ischemic  Muscular  Paralysis  and  Contracture. — T\lien  paralysis 
occurs  as  a  result  of  dh-ect  pressure  upon  a  nerve  trunk  the  condi- 
tion is  bad  enough,  but  an  even  more  hopeless  condition  may  fol- 
low if  the  blood  supply  of  the  part  is  seriously  interfered  with. 
Such  a  condition  may  follow  the  ligation  of  the  main  artery  of  a 
limb,  but  is  more  commonly  due  to  an  improperlj-  or  too  tightly 
applied  dressing,  particularly  inelastic  dressings.  It  may 
well  be  that  the  dressing  does  not  cause  an  artificial  anemia 
at  first,  but  only  after  some  swelling  has  occurred.  For  this 
reason  cases  in  which  plaster  dressings  or  other  nonelastic  dress- 
ings have  been  used  should  be  inspected  shortly  after  the  applica- 
tion of  such  dressing  in  order  to  insure  that  good  circulation 
is  present  in  the  part.  The  local  anemia  means  insufficient 
nutrition  of  the  muscles,  and  the  result  is  a  rapidl}'  progressive 
atrophy  which,  in  turn,  results  in  paralysis.  Electric  irritability 
diminishes,  faradic  reaction  is  lost  first,  later  galvanic.  Con- 
tractures ajjpear  early,  almost  simultaneously  with  the  paralysis. 
The  prognosis  is  very  unfavorable.  This  is  perhaps  because,  as 
a  rule,  the  condition  is  not  noted  until  a  change  of  dressing  is 
necessary,  by  which  time  the  atrophy  may  be  well  established. 
Only  in  the  milder  cases  is  recovery  possible.  Usually  not  only 
is  restoration  to  the  normal  impossible,  but  not  the  slighest  im- 
provement can  be  noticed.     The  contractures  increase  steadily. 


COMPLICATIONS    THE    RESULT    OF    ANTISEPTICS  297 

Treatment,  electricity,  massage  and  douches  should  be  continued 
for  months  in  any  event. 

These  ischemic  paralyses  are  noted  more  frequently  in  the 
treatment  of  fractures,  particularly  simple  fractures.  In  com- 
pound fracture  the  voluminous  aseptic  dressing  necessitated  by 
the  wound  allows  of  more  swelling  to  occur  inside  the  plaster 
cast  without  pressure  effects.  Moreover,  the  case  is  seen 
oftener,  as  the  wound  requires  change  of  dressing.  Since  these 
paralyses  occur  so  readily,  great  care  should  be  taken  in  the 
application  of  the  dressing,  which  should  be  inspected  frequently 
during  the  first  few  days.  The  patient  and  his  attendants 
should  be  instructed  to  be  on  the  watch  for  swelling.  This  will  be 
indicated  by  change  in  the  distal  portion  of  the  extremity,  which 
should  be  left  uncovered  for  this  very  purpose. 

Decubitis  (local  pressure  gangrene)  is  caused  by  a  continued 
pressure  over  a  part  of  the  body  not  protected  by  a  fatty  layer 
or  not  well  supplied  by  blood.  It  is  a  local  anemia  and  may 
result  from  pressure  of  a  bandage  or  apparatus,  as,  for  example, 
an  insufficiently  protected  splint.  It  may  occur  without  marked 
pain,  so  that  even  a  trivial  complaint  upon  the  part  of  a  patient 
should  be  inquired  into.  It  is  better  to  redress  a  wound  or  a 
part,  and  find  out  the  real  cause  of  discomfort,  than  to  neglect 
it,  only  to  find  out  later  that  a  local  gangrene  is  well  under  way. 
The  pain  of  which  the  patient  will  complain  will  usually  be 
described  as  a  burning.  Such  a  complaint  should  always  be 
investigated,  for  the  more  experience  one  has,  the  more  one 
realizes  that  patients  do  not  unnecessarily  complain  of  pain. 
When  the  dressing  is  changed  at  first  nothing  may  be  observed  to 
be  wrong,  but  upon  making  a  careful  search  it  will  be  found  that 
perhaps  a  safety-pin  holding  a  drainage  tube  is  pressing  against 
the  skin,  or  it  may  be  that  an  adhesive-plaster  strip  has  been  too 
tightly  applied,  or  that  the  edge  of  the  plaster  is  turned  against 
the  skin,  or  a  bony  prominence  may  not  have  been  sufficiently 
well  protected. 

Bedsores  usually  occur  in  the  neighborhood  of  the  sacrum, 
coccyx,  and  tuber  ischii.  They  are  very  apt  to  occur  in  paral- 
ysis of  cerebral  or  spinal  origin.  In  such  cases  it  is  not  necessary 
for  the  pressure  to  be  very  considerable  or  prolonged  to  produce 


298  OPERATIXG    ROOM    AXD    THE    PATIEXT 

local  gangrene.  Otlier  points  overlying  bony  prominences  may 
be  involved  according  to  the  position  of  the  patient.  The 
appearance  presented  vrhen  a  bedsore  is  about  to  occur  is 
characteristic.  There  is  a  reddish  discoloration  of  the  skin  at  the 
point  of  i^ressure.  This  is  followed  by  a  bluish  tint  which  sub- 
sequently changes  to  a  brown  or  black.  The  gangrenous  process 
involves  the  enthe  process  of  the  skin  and  may  even  extend  to 
the  underlying  osseous  stnictures.  Such  a  sore  may  show 
neither  a  tendenc}^  to  heal  nor  a  tendency  to  extend.  If  infection 
occurs  the  suppuration  may  result  in  an  extension  of  the  original 
sore. 

Treatment. — The  occurrence  of  pressure  sores  has  caused 
many  a  surgeon  to  regret  that  he  did  not  pay  more  attention  to 
the  details  of  his  work.  In  patients  who  are  long  confined  to  bed, 
massage  and  change  of  position  with  cleanliness  will  usually 
suffice  to  prevent  the  formation  of  bedsores.  In  paralytic  cases, 
a  water  or  ah  bed  should  be  employed.  '  In  cases  under  treat- 
ment for  a  very  considerable  length  of  time  only  the  utmost 
vigilance  will  ward  off  this  complication.  Elastic  cushions  and 
rings  may  be  used  to  change  the  position  of  the  patient  and  to 
relieve  the  bony  parts  from  pressure.  Daily  massage  of  the 
parts  with  alcohol  and  the  employment  of  drying  powders 
following  this  are  of  use.  If  in  spite  of  all  care  ulceration  occurs 
it  should  be  treated  antiseptic  ally.  Further  pressure  upon  the 
part  must  be  absolutely  prevented.  The  ulcerated  surface  should 
be  powdered  with  naphthalin  and  iodoform  in  equal  proportions 
and  dressed  with  antiseptic  gauze.  The  separation  of  sloughs 
may  be  hastened  by  the  vigorous  use  of  the  curette  and  by  wet 
dressings.  An  ointment  of  the  red  oxid  of  mercury  is  useful, 
also  an  ointment  composed  of  one  part  of  nitrate  of  silver,  five 
parts  of  Peruvian  balsam,  and  tw^enty  parts  of  lanolin.  In  intract- 
able cases  the  entire  ulcer  may  be  dissected  out,  including  the 
floor  and  margins,  and  the  resulting  fresh  wound  skin  grafted. 

CIRCULATORY  COMPLICATIONS. 

Prevention  of  the  Venous  Return. — Such  interference  is  shown 
by  cyanosis,  formication,  paresthesia  and  edema.  These  are 
trifling  and  easily  remedied  if  due  to  improper  bandaging,  but 


COMPLICATIONS    THE    RESULT    OF    ANTISEPTICS  299 

if  the  main  venous  trunk  has  been  tied  the  case  is  more  serious. 
In  such  cases  more  care  is  necessary  that  the  bandage  does  not 
still  further  interfere  with  the  return  flow.  Collateral  circula- 
tion and  the  passage  of  a  minimum  amount  of  blood  to  the  part 
should  be  favored  by  high  elevation  of  the  part. 

Thrombosis  of  the  Femoral  Vein. — In  patients  with  weak  heart, 
in  old  people,  and  in  debilitated  patients  long  rest  in  bed  is 
sufficient  to  cause  thrombosis  of  the  femoral  vein.  The  internal 
saphenous  vein  is  usually  also  involved.  The  location  of  the 
operation  does  not  seem  to  bear  any  relation  to  the  thrombosis. 
The  thrombus  usually  begins  at  the  junction  of  the  internal 
saphenous  with  the  femoral  vein.  There  is  an  uncomfortable 
sensation  of  weakness  and  weight  in  the  limb,  pain  over  the  site 
of  the  thrombus  and  along  the  course  of  the  vein,  and  a  numb 
sensation  in  the  limb.  Such  subjective  symptoms  are  accom- 
panied by  edema  varying  in  extent  according  to  the  development 
of  the  collateral  circulation.  There  is  coldness,  pallor  except  at 
the  periphery,  where  cyanosis  develops,  and  dilatation  of  the 
superficial  veins.  The  thrombosed  veins  feel  cord-like.  Move- 
ments of  the  limb  are  painful. 

A  well-developed  case  shows  involvement  of  the  internal 
saphenous  vein  and  the  femoral  vein  for  a  distance  of  several 
inches  below  Poupart's  ligament.  The  thrombus  may  extend 
into  and  block  the  external  iliac,  the  iliac,  and  even  the  inferior 
vena  cava,  extending  thence  into  the  iliac  vein  of  the  opposite 
side,  with  the  occurrence  of  the  same  symptoms  on  that  side. 
The  extension  of  the  thrombus  upward  will  be  shown  by  the 
dilatation  of  the  veins  on  the  abdominal  surface.  Both  sides 
may  be  affected  by  thrombi  almost  simultaneously.  In  the 
majority  of  cases  the  thrombus  does  not  extend.  The  clot 
becomes  organized  and  in  time  a  passage  for  the  blood  may  be 
made  through  it. 

This  unpleasant  complication  keeps  the  patient  in  bed  much 
longer  than  he  would  be  kept  by  the  healing  of  the  wound.  Even 
if  all  the  symptoms  disappear  while  in  bed,  yet  as  soon  as  the 
patient  gets  out  of  bed  the  symptoms  reappear,  at  least  in  part, 
and  several  months  must  elapse  before  a  normal  condition  is 
attained.     Indeed,  in  weak  patients  or  patients  with  weak  heart 


300  OPERATING  ROOM  AND  THE  PATIENT 

action  the  condition  may  become  permanent.  During  the  first 
few  weeks,  while  the  thrombus  is  still  soft,  there  is  danger  of 
some  of  the  clot  becoming  detached  and  forming  emboli  in  the 
lungs. 

Treatment. — In  cases  which  are  to  be  kept  quiet  in  bed  for 
some  time,  in  cases  with  weak  heart,  in  debilitated  patients,  and 
in  old  people,  the  limbs  should  be  massaged  daily  and  the  heart 
action  stimulated.  If  in  spite  of  prophylaxis  thrombosis  does 
occur,  the  treatment  consists  in  moderate  elevation  of  the  limb 
to  keep  as  little  blood  as  possible  passing  through  the  limb, 
absolute  rest,  the  avoidance  of  any  but  the  most  necessary 
cardiac  stimulation.  There  must  be  no  active  treatment  until 
the  clot  is  organized,  which  will  be  in  about  three  weeks.  Follow- 
ing this,  massage  and  bandaging  may  be  used  to  dispel  the  edema. 

Occasionally  such  a  thrombus  becomes  infected.  If  so,  the 
onset  of  the  infection  is  shown  by  a  rise  in  temperature  and  a 
chill,  with  increased  tenderness  over  the  thrombus.'  Septic 
emboli  may  be  carried  to  the  lungs  and  death  ensue  either  from 
pulmonary  embolism,  septic  pneumonia  or  general  sepsis.  In 
such  a  case  the  only  treatment  which  will  be  of  avail  will  be  the 
excision  of  that  portion  of  the  vein  containing  the  infected 
thrombus  before  pulmonary  embolism  occurs.  The  least  that 
can  be  done  is  proximal  ligature  of  the  infected  vein. 

Phlebitis  of  the  Internal  Saphenous  Vein. — Without  thrombosis 
there  may  occur  an  inflammatory  condition  of  the  internal 
saphenous  vein  with  the  following  symptoms:  pain,  most 
marked  at  the  saphenous  opening;  tenderness  along  the  course  of 
the  internal  saphenous  vein;  rigidity  of  the  muscles  along  the 
inner  side  of  the  thigh.  Such  a  phlebitis  may  occur  in  all  classes 
of  patients  and  as  a  complication  of  all  operations,  irrespective 
of  the  previous  condition  of  the  patient  or  of  the  duration  of 
the  stay  in  bed.  It  seems  to  be  more  frequent  after  abdominal 
operations  than  after  operations  on  other  parts  of  the  bod3\ 
That  there  is  no  thrombus  present  would  seem  to  be  proved  by 
the  short  duration  of  the  symptoms  and  by  the  fact  that  the 
symptoms  are  not  severe.  The  treatment  consists  in  rest, 
enveloping  the  limb  in  cotton,  moderate  elevation  of  the  limb, 
supporting  bandages,  and  counter-irritation  over  the  course  of 


COMPLICATIONS    THE    RESULT    OF    ANTISEPTICS  301 

the  vein.  The  duration  is  usually  a  few  days,  though  the 
symptoms  may  persist  for  a  few  weeks.  The  same  condition 
may  present  in  the  course  of  the  external  saphenous. 

Air  Embolism. — The  entrance  of  air  into  the  veins,  though  a 
rare  circumstance,  is  one  that  must  be  guarded  against  both 
during  operations  in  the  neighborhood  of  large  veins,  particularly 
those  of  the  neck,  and  in  the  after-care  of  operations  in  the 
neighborhood  of  large  veins  in  which  packing  has  been  used 
to  arrest  hemorrhage  or  in  which  septic  processes  are  active. 
The  accident  has  happened  in  connection  with  operations  upon 
the  internal  and  external  jugular,  the  subclavian  vein,  the 
cerebral  sinuses,  the  facial,  axillary,  subscapular,  thoracic  and 
femoral  veins,  and  enlarged  veins  in  the  neighborhood  of  malig- 
nant tumors.  The  entrance  of  air  into  a  vein  is  characterized 
by  a  hissing  sound.  If  only  a  small  amount  enters  no  appreciable 
effect  may  be  noted.  In  case  of  larger  quantities  labored 
breathing  and  rapid  heart  action  will  result.  If  sufficient  air 
has  entered  to  fill  the  right  side  of  the  heart,  death  may  occur  at 
once,  the  air  preventing  the  contraction  of  the  right  ventricle. 

Treatment. — ^Pressure  should  be  made  upon  the  proximal 
portion  of  the  injured  vein  and  the  wound  flooded  with  saline 
solution  until  the  vessel  is  secured.  Artificial  respiration, 
inhalations  of  oxygen,  electricity  applied  over  the  cardiac  area, 
and  intravenous  saline  infusion  should  be  employed,  together 
with  the  usual  treatment  for  shock. 

In  repacking  a  wound  in  the  neighborhood  of  a  large  vein  a 
mass  of  gauze  should  be  at  hand  to  rapidly  plug  the  wound  in 
case  of  erosion  of  the  vein. 

Fat  embolism  is  a  rare  complication.  Fat  globules  are  found 
in  the  urine  of  practically  all  cases  of  fracture.  Since  symptoms 
from  the  presence  of  the  fat  in  the  blood  are  rarely  seen  it  must 
follow  that  a  very  appreciable  amount  of  fat  must  be  forced 
into  the  circulation  to  result  disastrously.  Fat  may  find  its 
way  into  the  blood  in  fractures,  in  acute  inflammatory  diseases 
of  bones,  in  injuries  to  the  liver  and  in  injuries  involving  fatty 
tissues  generally.  It  has  not  been  observed  in  fractures  in 
childhood  probably  because  the  medulla  is  comparatively  free 
from  fat  in  early  life. 


302  OPERATING    ROOM    AXD    THE    PATIEXT 

Autopsies  show  that  when  an  appreciable  quantity  of  fat 
has  found  its  way  into  the  circulation  the  pulmonary  capillaries 
become  plugged.  Small  Ciuantities  may  be  forced  through  and 
disseminate  without  giving  rise  to  symptoms.  Larger  quantities 
cause  pulmonary  thrombosis  and  edema.  If  the  patient  survive 
the  pulmonary  thrombosis  the  capillaries  in  other  organs, 
kidney,  brain,  etc.,  become  plugged  and  symptoms  accordingly 
will  be  observed. 

The  earliest  symptoms,  appearing  from  a  few  hours  to  a  few 
days  following  injury,  are  those  of  pulmonary  thrombosis;  at 
fu'st  increased  respiration,  dyspnea  and  pallor  followed  by 
cyanosis  and  weakened  circulation,  and  later  pulmonary  edema. 
Cerebral  symptoms,  delirium,  somnolence,  coma  and  occasionally 
paralyses  or  convulsions  follow,  if  the  patient  survive  sufficiently 
long. 

Occurring  immediately  after  an  injury  the  lesion  may  be 
mistaken  for  shock.  The  later  occurrence  of  fat  embolism  serves 
in  most  cases  to  differentiate  it.  In  shock  the  patient  is  pallid, 
the  temperature  subnormal,  the  respirations  shallow;  in  fat 
emboli,  the  patient  is  cyanotic,  the  temperature  more  approxi- 
mately normal,  the  respiration  stertorous.  The  pulmonary 
signs  and  weak  pulse  of  fat  embolism  will  differentiate  it  from 
apoplexy,  intracranial  hemorrhage  or  ordinarj^  embolism.  The 
diagnosis  may  be  confirmed  b}^  the  appearance  of  small  hemor- 
rhages into  the  skin  and  mucous  membrane.  Urinary  examina- 
tion will  in  the  majority  of  cases  show  fat.  Ophthalmoscopic 
examination  may  show  fat  droplets  in  the  retinal  vessels.  Acute 
suppression  oi  urine  after  injury  or  operation  should  cause  the 
suspicion  of  fat  embolism. 

Shock. — Shock  is  most  frequently  observed  in  young  children, 
the  aged,  and  weak  individuals.  Children  rapidly  recoA^er  from 
its  effects.  The  most  prominent  symptom  is  extreme  weakness 
of  the  heart's  action.  The  preventive  treatment  consists  in 
encouraging  the  patient  as  to  the  outcome  of  the  operation,  in 
preliminary  rest  in  bed,  in  the  prevention  of  cooling  of  large 
surfaces  of  the  body  during  anesthetization,  in  careful  anes- 
thetization and  in  the  avoidance  of  loss  of  blood.  In  amputa- 
tions cocain  should  be  injected  into  the  main  nerve  trunk  of 


OPERATIONS    UPON    SPECIAL   TISSUES  303 

the  limb  (Crile).  In  patients  already  the  victims  of  shock  only 
the  most  imperative  operations  should  be  performed,  and  these 
should  be  done  with  as  much  expedition  as  possible. 

Treatment. — The  treatment  is  the  same  as  for  hemorrhage, 
except  the  local  treatment  of  the  wound.  Nitroglycerin  and 
amyl  nitrite  are  contraindicated  on  account  of  the  vasomotor 
dilatation  which  they  produce. 

Cause  of  Sudden  Death  following  Operation. — Acute  cardiac 
dilatation  may  occur  at  any  time  following  an  operation.  Some- 
times death  occurs  at  so  remote  a  period  as  to  leave  one  in  doubt 
whether  there  was  any  connection  between  the  operation  and 
the  sudden  death.  In  seven  cases  occurring  in  our  experience^ 
death  occurred  from  ten  to  twenty-one  days  following  the 
operation,  and  always  in  cases  which  were  proceeding  unevent- 
fully and  which  held  out  every  hope  of  recovery.  In  the  last 
of  these  cases,  a  case  of  hemorrhoids,  death  occurred  just  as 
the  patient  was  about  to  leave  the  hospital,  as  the  patient  was 
walking  from  the  toilet  to  his  room.  Autopsy  demonstrated 
acute  cardiac  dilatation  with  no  other  lesion.  There  is  no  way 
of  prognosticating  the  occurrence  of  this  complication. 


CHAPTER  XI. 
OPERATIONS  UPON  SPECIAL  TISSUES. 

The  Skin  and  Subcutaneous  Structures. — Cicatrization.  Skin-grafting. 
Open  treatment  of  skin-grafted  surfaces.  Plastic  operations.  Complications 
occurring  in  scar  tissue.  Keloid.  Latent  infections  in  scar  tissue.  Opera- 
tions for  moles.     Syndactylism.     Operations  upon  the  nails. 

Tendon  and  Muscle. — Tendon  suture.  Tenorrhaphy.  Tendon  and  mus- 
cle transplantation.  Continuity.  Complication  by  suppuration.  Treat- 
ment. Muscular  suture.  Tenotomy  and  myotomy.  Tuberculous  teno- 
synovitis.    Dupuytren's  contracture.     Contracture  of  the  finger-joints. 

The  Vascular  System. — Secondary  hemorrhage.  Disturbance  of  circula- 
tion. Ligature  of  the  external  iliac,  femoral,  axUlary,  subclavian,  common 
carotid.  Varicosities  of  the  saphenous  vein.  Impending  gangrene  following 
high  ligation  of  the  femoral  vein.  Thrombosis  and  embolism.  Aneurysm. 
Complications.     Infections.     Secondary  hemorrhage. 

The  Lymphatic  System. — Lymphatic  edema.  Lymphangeioplasty.  Lymph- 
orrhea.     Lymphangiectasis.     Persistent  fistula.     Adenectomy. 

*  Six  cases  cited  in  Fowler's  Surgery. 


304  OPERATING    ROOM    AXD    THE    PATIENT 

The  Nervous  System. — Peripheral  nerves.  Xerve  resection.  Xerve 
suture.  Xerve  anastomosis.  Course  foUo'n-ing  nerve  anastomosis  for 
facial  parah-sis.  Spinal  accessorj-  nerve.  Hypoglossal  nerve.  Suture  of 
the  brachial  plexus.  Xerve-stretching.  Xeedling.  Xeurotomy  and  neu- 
rectomy for  painful  conditions.  Trophic  disturlaances.  Dryness  of  skin. 
Disturbances  of  circulation.  Operations  upon  the  spinal  cord  and  posterior 
nerve  roots.     Underlying  principles. 

OPERATIONS  UPON  THE  SKIN  AND  SUBCUTANEOUS  TISSUES. 

Such  wounds  usually  heal  m  from  five  to  ten  days.  Super- 
ficial skin  ^vounds  may  heal  in  a  shorter  period.  The  further 
process  of  cicatrization  rec^uires  a  much  longer  time  and  depends 
upon  the  amount  of  tension  to  Avhich  the  young  scar  is  subjected, 
either  through  its  position  or  by  the  earl}"  use  of  the  part.  The 
amount  of  tension  varies.  It  "O'ill  be  much  greater  if  the  incision 
is  at  right  angles  to  the  lines  of  normal  skin  cleavage  than  if  it 
Avere  parallel  to  these  lines.  The  operator  should  bear  this  fact 
in  mind  and  should  conform  the  incision,  as  nearly  as  the  exi- 
gencies of  the  case  will  permit,  to  the  lines  of  normal  skin  cleavage. 
Even  Avitli  the  most  careful  attention  in  this  regard  and  with 
beveled  incisions,  there  will  result  but  a  small  percentage  of 
"invisible"  cicatrices.  For  cosmetic  reasons  such  scars  are 
particularly  to  be  desired,  but  are  extremely  difficult  to  obtain. 

The  young  cicatrix,  however  narrow  it  may  be,  differs  in 
color  from  the  surrounding  skin.  Until  cicatrization  is  begun 
there  is  apparent  to  the  eye  a  thin,  dark  red  line  formed  by 
coagulated  blood,  which  marks  the  site  of  the  incision.  The 
skin  for  the  space  of  one-eighth  to  one-C[uarter  of  an  inch  on 
either  side  of  the  incision  is  slightly  reddened.  From  the 
seventh  day  the  character  of  the  line  of  the  incision  gradually 
changes  and  by  the  tenth  day  there  is  a  distinct  rosy  appearance 
of  the  young  cicatrix.  This  is  due  to  the  formation  of  new 
blood-vessels.  The  surrounding  skin  has  now  resumed  its 
normal  appearance.  The  rosy  color  of  the  scar  becomes  more 
marked  for  a  period  of  several  weeks  or  months.  During  ex- 
ertion the  minute  blood-vessels  become  congested  and  give 
an  angry  appearance  to  the  scar.  Gradually,  however,  the 
color  fades  until  a  pearly  white  band  is  all  that  marks  the  site  of 
the  incision.     The  scar  never  assumes  the  complete  appearance 


OPERATIONS    UPON    SPECIAL    TISSUES  305 

of  normal  skin,  owing  to  the  absence  of  pigment.  This  color  con- 
trast is  more  marked  if  the  scar  is  broad. 

Except  under  the  best  conditions  in  the  most  perfect  primary 
union  the  scar  becomes  broader  as  time  goes  on.  Secondary 
union  results  in  a  still  broader  and  more  disfiguring  scar.  Even 
after  years  have  passed  scars  of  this  latter  class  will  assume  an 
angry  red  color  during  severe  exertion  or  strong  emotion.  The 
broadening  of  the  scar  is  due  to  the  elastic  tension  of  the  skin,  a 
constantly  acting  force  in  those  incisions  which  are  at  right 
angles  to  the  line  of  normal  cleavage.  As  long  as  the  sutures  are 
in  place  this  force  is  successfully  combatted,  but  upon  their 
removal  the  young  cicatrix  is  gradually  but  surely  stretched 
until  after  months  a  scarcely  perceptible  linear  scar  may  become 
a  broad,  pearly  white,  disfiguring  band.  In  wounds  of  this 
character  the  treatment  is  mostly  preventive.  The  incision 
should  be  made  in  the  'line  of  normal  skin  cleavage.  Sutures 
should  be  allowed  to  remain  at  least  seven  days,  and  if  there  are 
no  symptoms  of  irritation  ten  days,  or  even  fourteen  to  twenty- 
one  days  in  cases  in  which  the  tension  is  very  great.  The  young 
cicatrix  should  be  supported  by  painting  it  and  the  surrounding 
skin  with  collodion.  Adhesive-plaster  straps  should  be  employed 
at  a  distance  from  the  scar  to  draw  the  neighboring  skin  in  the 
direction  of  the  scar  and  thus  further  support  it.  The  collodion 
painting  should  be  employed  for  several  weeks  until  the  scar  has 
become  firmer  and  more  resistant.  But  even  with  every 
precaution,  if  the  wound  is  at  right  angles  to  the  line  of  normal 
cleavage  the  constantly  acting  elastic  traction  of  the  adjacent 
skin  will  serve  to  broaden  the  cicatrix  somewhat.  The  great 
amount  of  stretching  of  which  the  scar  is  capable  is  exemplified 
in  post-operative  hernia  and  in  the  broad  scars  on  the  chest 
following  extensive  removal  of  carcinoma  mammae. 

The  mature  cicatrix  offers  great  and  often  successful  resistance 
to  the  forces  seeking  to  stretch  it.  This  tendency  to  contraction 
is  inherent  in  all  scar  tissue.  The  greater  the  amount  of  scar 
tissue,  the  greater  the  final  contraction  to  be  expected.  The 
neighboring  skin  is  drawn  upon  and  contractures  and  much 
disability  may  result.  When  favorably  placed  this  contraction 
may  cause  an  unsightly  scar  to  become  an  insignificant  spot. 

20 


306 


OPERATING    ROOM    ANB    THE    PATIENT 


The  cicatrices  following  Thiersch  skin-grafting  are  not  as 
disfiguring  or  liable  to  contraction  as  the  cicatrix  of  secondary 
union.  The  technic  of  the  procedure  must  be  perfect  to  attain 
the  best  results.  Though  the  cosmetic  effect  is  not  nearly  so 
good  as  that  of  a  linear  scar,  yet  the  color  more  nearly  approaches 
that  of  normal  skin.  If  the  grafts  are  not  of  uniform  thickness 
or  if  they  are  not  very  closely  applied,  considerable  cosmetic 
deformity  will  result. 

Skin-grafting. — This  is  indicated  in  all  wounds  of  any  magni- 
tude of  the  superficial  parts  which  do  not  allow  of  secondary 
suturing.  The  grafts  are  preferably  placed  on  the  wound  surface 
before  granulation  is  well  under  way.     If,  however,  the  wo'jnd  is 


Fig.    liV.i/ — Cutting  a  skin-graft.      (Fowler's  Surgery.) 


granulating,  the  granulations  should  be  leveled  and  bleeding 
arrested  by  pressure  before  the  grafts  are  placed.  Only  with 
practice  can  adeptness  be  gained.  The  grafts  are  best  taken 
from  the  anterior  surface  of  the  thigh.  If  this  is  unavailable  for 
any  reason  the  outer  surface  of  the  arm  may  be  utilized.  No 
antiseptics  are  used  in  the  preparation  or  course  of  the  procedure. 
Following  a  soap  and  water  cleansing  the  parts  are  flushed  with 
saline  solution.  A  skin-grafting  razor  or  an  ordinary  razor  is 
used  in  cutting  the  grafts;  the  main  requisite  being  that  the  in- 
strument be  very  sharp.  The  skin  is  put  upon  the  stretch  and 
made  prominent  by  encircling  the  part  with  the  hand  slightly 


OPERATIONS    UPON    SPECIAL    TISSUES 


307 


in  advance  of  the  razor.  If  any  apprehension  is  felt  that  the 
razor  may  slip  the  hand  may  be  guarded  by  a  piece  of  gauze. 
With  the  skin  on  the  stretch  long  narrow  strips  of  a  thickness  of 
only  a  portion  of  the  thickness  of  the  skin  are  shaved  off  by  a 
sawing  motion  of  the  razor.  The  razor  is  held  parallel  with  the 
skin  surface.  It  is  desirable  to  make  these  strips  the  same  length 
as  the  surface  to  be  grafted.  With  practice  strips  an  inch  wide 
or  an  inch  and  a  half  wide  and  as  long  as  desired  can  be  secured. 
When  the  razor  approaches  the  hand,  the  hand  is  moved  further 
away.  McBurney's  skin-stretching  hooks  may  be  used  (Figs. 
163  and  164).  The  strips  should  be  of  uniform  thickness  and 
breadth.  A  gentle  stream  of  saline  at  a  temperature  of  100°  F. 
is  directed  over  the  field  during  the  procedure.     The  strips  are 


Fig.  164. — McBurney's  skin-stretching  hooks.     (Fowler's 
Surgery.) 


applied  directly  to  the  surface  to  be  grafted.  They  are  spread 
flat  and  evenly  and  the  tendency  of  their  edges  to  curl  under  is 
corrected  by  gentle  manipulation  with  a  slender  flat-ended 
probe.  The  entire  surface  is  covered  with  grafts  which  should  lie 
edge  to  edge  but  should  not  overlap.  The  area  from  which  the 
skin  was  taken  is  dressed  with  boric  acid  ointment.  The  grafted 
wound  is  dressed  with  narrow  strips  of  green  silk  protective 
arranged  as  a  basket  strapping,  with  spaces  left  for  the  escape  of 
wound  discharge  (Fig.  165).  This  is  covered  with  a  copious 
aseptic  gauze  dressing  moistened  with  saline  solution.  Over 
this  is  placed  a  layer  of  nonabsorbent  cotton  and  the  whole  is 
held  in  place  by  a  roller  bandage.  This  dressing  is  moistened 
from  time  to  time  with  saline  without  disturbing  the  wound. 
The  first  dressing  is  done  in  three  days.  Before  removing  the 
gauze  and  silk  straps  the  dressing  is  thoroughly  moistened,  but 
no  stream  of  solution  should  be  allowed  to  play  upon  the  wound 
for  fear  of  loosening  and  washing  away  some  of  the  grafts.     The 


308  OPERATIXG    ROOM    AXD    THE    PATIEXT 

dressing  is  renewed  and  changed  every  second  day  until  healing  is 
complete.  At  each  dressing  grafts  or  portions  of  grafts  which 
have  not  taken  are  removed  with  sharp-pointed  scissors  to  pre- 
serve an  aseptic  condition  of  the  wound. 


Fig.  165. — Basket  strapping  dressing  for  skin-grafting.     (Fowler's  Surgery.) 

Open  Treatment  of  Skin -grafted  Surfaces. — A  well  of  gauze  is 
built  up  around  the  grafted  area  and  on  top  is  placed  a  sheet  of 
wire  gauze.  The  whole  is  held  in  place  by  adhesive-plaster 
strips  placed  so  as  not  to  interfere  with  the  ventilation  of  the 
wound.  The  healing  process  is  watched  through  the  wire  mesh 
and  is  usually  complete  enough  in  ten  or  twelve  days  to  allow  of 
the  application   of  a  simple  gauze  dressing. 

Plastic  Operations. — In  order  to  secure  a  good  final  result 
it  is  essential  that  the  amount  of  shrinkage  of  the  flap  and  the 
amount  of  cicatricial  contraction  be  correctly  judged,  and  due 
allowance  made  at  the  time  of  operation.  If  too  small  a  flap  is 
employed,  and  allowance  for  shrinkage  not  made,  the  immediate 
result  may  appear  perfect,  but  the  final  result  will  be  bad.     On 


OPERATIONS    UPON    SPECIAL    TISSUES  309 

the  other  hand,  if  too  large  a  flap  be  employed,  the  final  result 
will  not  be  so  imperiled,  though  the  immediate  result  be  bad. 
In  flaps  which  are  covered  on  both  sides  by  skin  and  mucous 
membrane,  if  exact  union  is  obtained  there  will  be  but  slight 
secondary  contracture.  If  the  flap  is  loosened  from  the  under- 
lying connective  tissue  shrinkage  cannot  be  avoided  and  its 
amount  cannot  always  be  gauged.  There  is  an  immediate 
shrinkage  due  to  the  normal  elasticity  of  the  skin,  and  a  second- 
ary shrinkage  due  to  cicatricial  contraction.  This  is  not  so 
marked  if  primary  union  occurs,  but  if  the  healing  process  has 
been  left  in  part  to  granulation  the  retraction  will  be  considerable. 
The  edge  of  the  flap  rolls  up  on  itself  along  the  border  of  the 
granulating  wound.  A  small  amount  of  blood  under  the  flap 
will  be  suflicient  to  cause  its  elevation.  The  object  of  the  after- 
treatment  is  to  keep  the  surfaces  in  exact  apposition  and  thus 
prevent  the  elevation  of  the  flap  and  promote  rapid  healing. 
A  thin  lead  or  silver  plate  may  be  placed  over  the  flap  with  this 
object  in  view.  Sheets  of  silver  foil  or  strips  of  oil-silk  protective 
may  be  employed.  Gentle  pressure  is  continued  until  healing 
is  effected,  and  thereafter  at  intervals  of  at  least  a  few  hours 
every  day  until  cicatrization  is  complete.  The  patient  is  in- 
structed to  bind  the  metal  plate,  which  conforms  to  the  shape 
of  the  part,  over  the  flap  for  several  weeks.  In  case  edema  of 
the  flap  occurs  the  same  pressure  treatment  is  to  be  employed. 
The  edema  usually  subsides  rapidly. 

At  the  point  where  the  pedicle  of  the  flap  was  twisted,  in 
order  to  bring  the  flap  accurately  into  the  defect,  there  is  apt  to 
remain  a  slight  deformity.  This  is  readily  remedied  by  a 
secondary  operation,  but  this  is  better  undertaken  when  cicat- 
rization is  complete,  and  surely  not  before  the  integrity  of  the 
blood  supply  of  the  flap  is  assured.  Deforming  cicatrices  should 
not  be  removed  until  the  process  of  contraction  has  been  com- 
pleted. The  adhesion  of  the  cicatrix  to  bone  may  cause  consider- 
able deformity.  This  is  particularly  true  in  wounds  of  the  face, 
where  the  adhesion  of  the  cicatrix,  by  limiting  the  mobility  of 
the  muscle,  may  simulate  a  partial  paralysis.  These  cases  are 
not  to  be  hastily  operated  upon,  as  massage  carried  out  system- 
atically for  weeks  and  which  may  be  done  by  the  patient,  accom- 


310  OPERATING    ROOM    AND    THE    PATIENT 

plishes  much.     An  excision  of  the  scar  is  likely  to  be  followed  by 
a  recurrence  of  the  deformity. 

In  plastic  operations  in  which  a  defect  is  corrrected  by  a  flap 
situated  at  a  distance  from  the  defect  with  its  base  or  bases  left 
attached,  extraordinary  care  is  essential  to  success.     Absolute 
immobility  must  be  maintained  until  the  flap  has  become  firmly 
attached.     This  necessitates  great  discomfort  to  the  patient. 
Plaster  of  Paris  combined  with  adhesive  plaster  forms  the  most 
stable   dressing.     The   dressing   must   not    only   fix   the   parts 
absolutely,  but  must  make  the  patient  as  comfortable  as  possible. 
The  pressure  must  be  equally  distributed.     The  fixation  dressing 
should  be  so  applied  as  to  allow  of  ready  inspection  of  the  wound 
without  disturbing  the  relation  of  the  parts.     A  copious  wound 
dressing  is  applied.     Drainage  is,  as  a  rule,   unnecessary.     All 
places  where  there  are  folds  in  the  skin  or  where  skin  surfaces 
come   into   contact   should   be   protected    against   excoriation, 
especially  in  neighborhoods  where  sweat  and  sebaceous  follicles 
abound.     Otherwise  an  annoying  eczema  will  develop,  following 
which  infection  of  the  wound  may  follow.     Unless  infection 
occurs  there  is  no  need  of  redressing  the  wound  until  the  tenth 
or  fourteenth  day.     The  fixation  dressing  is  not  disturbed.     If 
healing  is  firmly  established,  the  base  or  bases  of  the  flap  may  be 
separated  with  sharp  scissors  or  a  scalpel  and  the  fixation  dressing 
removed.     If  healing  has  not  progressed  satisfactorily,  a  fresh 
wound   dressing   is   applied,   but   the  fixation   dressing   is   not 
disturbed.     After  the  lapse  of  five  to  seven  days  the  wound  is 
again  inspected  and  the  base  of  the  flap  severed  and  the  fixation 
dressing  removed.     This  is  followed  by  a  marked  anemia  of  the 
flap.     This  need  not  cause  anxiety,  as  unless  gangrene  has  already 
taken  place  at  the  margin  of  the  flap,  the  new  vessels  coming  in 
from  the  edge  and  through  the  under  surface  of  the  flap  will  be 
sufficient  to  nourish  it.     Even  pressure  is  all  that  is  subsequently 
required.     There  is  anesthesia  of  the  flap  at  first,  but  finally 
sensation  is  as  complete  as  in  the  surrounding  skin.     In  some 
cases  it  may  be  best  to  sever  the  base  gradually,  taking  several 
days  for  the  process. 

Complications  Occurring  in  Scar  Tissue. — Scar  tissue  is  little 
resistant  to  infection  and  injury.     An  abscess  may  occur.     A 


OPERATIONS    UPON    SPECIAL    TISSUES  311 

foreign  body,  such  as  a  ligature,  owing  to  the  limited  vital  resist- 
ance of  the  scar  readily  causes  suppuration.  In  a  recent  scar 
ulceration  may  be  caused  by  pressure  or  chaffing  of  the  clothing. 
In  recent  scar  tissue  ulceration  readily  heals,  but  later  on,  when 
the  blood  supply  is  not  so  rich,  ulcerated  areas  are  slow  in  healing, 
A  painful  condition  of  the  scar  may  result  from  the  inclusion 
of  nerve  filaments.  As  the  scar  contracts  this  may  be  due  to 
direct  pressure  upon  a  nerve  or  to  adhesion  to  a  nerve-sheath. 

Keloid. — Negroes  seem  to  be  particularly  susceptible  to 
keloid.  The  cause  of  keloid  is  obscure.  It  is  due  to  some  de- 
generative change  in  the  scar  tissue,  characterized  by  increased 
density  and  increased  vascularity  of  the  scar.  The  scar  becomes 
broader,  thicker,  and  involves  irregularly  the>  neighboring  skin, 
the  surface  becomes  irregular,  raised  knobs  are  formed.  A  scar 
the  seat  of  keloid  is  very  unsightly.  Burning  or  itching  will  be 
complained  of.  The  color  becomes  deep  pink,  in  negroes  black. 
Microscopically  the  disease  seems  to  be  a  simple  hypertrophy  of 
the  scar.  Usually  the  entire  cicatrix  is  involved,  occasionally 
only  a  part.  Every  stitch-hole  may  be  marked  by  a  hypertroph}^ 
the  size  of  a  pea.  Infection  seems  to  play  no  part.  It  occurs 
quite  as  frequently  after  primary  as  after  secondary  union.  It 
may  occur  soon  after  union  is  affected  or  not  appear  for  weeks. 
The  growth  is  slow  until  a  certain  size  is  attained,  when  the  keloid 
remains  stationary.  Atrophy  does  not  occur.  Excision  is 
followed  almost  without  exception  by  recurrence,  which  is  apt 
to  be  more  extensive  than  the  original  keloid. 

Treatment. — Excision  should  not  be  attempted.  Electrolysis 
(Hardaway),  elastic  pressure  (Verneuil),  and  multiple  scarifica- 
tions followed  by  inunctions  of  mercurical  ointment  are  recom- 
mended but  are  rarely  successful.  Repeated  exposure  to  Rbnt- 
gen  rays  will  cause  the  flattening  and  partial  disappearance  of 
recent  and  small  keloids.  In  larger  keloids  and  those  of  long 
standing  the  effect  is  not  marked.  Repeated  exposure  to  the 
X-ray  is  successful  in  some  cases  in  causing  a  disappearance  of 
the  keloid. 

Pseudo-keloid  occurs  after  the  healing  of  tuberculous  sinuses. 
The  knobby  scar  tissue  resembles  normal  skin  more  closely  than 
in  true  keloid.     Excision  is  not  followed  by  recurrence. 


312  OPERATING    ROOM    AND    THE    PATIENT 

Malignant  degeneration  in  scar  tissue  is  occasionally  noted  in 
old  cicatrices  following  operation  for  injury  or  nonmalignant 
disease.  The  disease  is  of  the  carcinomatous  type,  but  save  in 
cases  of  great  malignancy  does  not  extend  beyond  the  skin.  It 
may  follow  prolonged  ulceration  of  the  scar,  or  occur  as  a  primary 
disease.  The  former  is  the  more  common,  as  exemplified  by  pri- 
mary malignant  disease  occurring  in  old  leg  ulcers  and  following 
lacerations  of  the  cervix  uteri.  In  epithelioma  occurring  in  old 
ulcers  there  is  some  reason  to  suppose  that  titrate  of  silver  or 
other  cauterizing  agents  may  have  contributed  through  irritation 
to  the  formation  of  the  malignant  disease. 

Latent  Infections  in  Scar  Tissue. — In  cases  such  as  deep  ab- 
scesses of  the  forearm  which  have  been  opened,  thoroughly 
drained,  and  allowed  to  heal  by  the  slow  process  of  granulation  in 
place  of  being  secondarily  sutured,  there  will  naturally  result  an 
excessive  formation  of  scar  tissue.  The  skin  scar  will  be  broad 
and  will  be  slow  in  approaching  the  characteristics  of  normal  skin. 
The  process  may  not  be  completed  until  six  or  eight  months 
have  elapsed.  Such  cases  are  susceptible  to  infection  in  the  scar 
tissue,  which  may  take  place  a  week  or  ten  months  or  a  year 
following  wound  healing.  In  these  cases  the  remote  infection 
seems  to  occur  in  the  depths  of  the  scar  tissue,  not  in  the  skin 
scar,  nor  is  the  skin  scar  involved  except  through  a  direct  exten- 
sion of  the  infective  process.  For  this  reason  it  is  reasonable  to 
suppose  that  germs  either  have  Iain  dormant  in  the  depths  of 
the  wound  from  the  time  of  the  original  infection,  or  have  been 
brought  to  the  depths  by  the  blood-vessels  and,  lodging  there, 
found  a  point  of  less  resistance.  The  treatment  consists  in 
evacuating  the  pus  and  getting  the  wound  clean  by  frequent 
dressing  and  disinfection.  When  this  has  been  accomplished 
the  old  scar  tissue  should  be  dissected  out  and  secondary  suturing 
done. 

Operations  for  Moles. — Incomplete  operations,  such  as  cau- 
terization and  excisions  not  wide  of  the  growth,  are  apt  to  be 
followed  by  melano-sarcoma  either  in  the  neighborhood  of  the 
original  growth  or  at  a  distance. 

Syndactylism. — Didot's  Operation.  Scars  along  the  dorsum 
do  not  interfere  with  the  future  usefulness  of  the  hand  but  scars 


OPERATIONS    UPON    SPECIAL    TISSUES 


313 


along  the  palmar  surface  are  apt  to  result  in  palmar  contraction 
and  interference  with  extension.  To  prevent  this  a  dorsal  splint 
should  be  worn  to  keep  the  finger  in  which  the  dorsal  flap  has 
been  used  extended.  To  be  effective  such  a  splint  must  extend 
beyond  the  end  of  the  finger  and  above  the  wrist  (Fig.  166). 
This  splint  should  be  worn  for  two  months  being  removed  for  a 
few  minutes  daily  to  permit  of  passive  motion.     At  the  end  of 


Fig.   166. — Dorsal  splint  for  after-treatment  of  syndactylism. 


two  months  it  may  be  left  off  during  the  day  but  is  replaced  at 
night  for  a  long  period,  generally  six  months  to  a  year.  This 
palmar  contraction  is  lessened  by  securing  linear  union  at  the 
original  operation.  If  this  is  not  possible  without  undue  tension 
skin-grafting  should  be  done. 

Operations  on  the  Nails. — ^Following  complete  or  partial 
excision  of  the  nail  for  paronychia  a  copious  evaporating  mildly 
antiseptic  dressing  (alcohol-bichlorid)  is  applied.  This  is  kept 
moist,  frequently  changed  and  made  smaller  as  the  inflammation 
subsides.     Following  subsidence  of  the  inflammation  boric  acid 


314  OPERATING    ROOM    AND    THE    PATIENT 

ointment  is  applied  until  the  new  epithelium  at  the  base  of  the 
nail  ceases  to  be  tender.  A  new  nail  is  formed  in  four  to  six 
months. 

Following  excision  of  ingrown  toe  nail  the  same  procedure  is 
followed  if  there  is  much  outlying  inflammation;  otherwise  an 
ointment  dressing  may  be  immediately  applied.  The  length  of 
time  the  parts  are  kept  quiet  depends  upon  the  amount  of  pain. 
Proper  shoes  should  be  advised. 

OPERATIONS  UPON  TENDON  AND  MUSCLE. 

Tendon  Suture,  Tenorrhaphy,  Tendon  or  Muscle  Transplanta- 
tion.— -While  in  operations  upon  the  skin  the  primary  object  is 
to  obtain  a  good  cosmetic  result,  in  operations  upon  tendons  and 
muscles  the  functional  result  is  of  the  first  importance.  This 
result  depends  on  the  after-treatment  as  much  as  on  the  operation 
itself.  An  operation  alone  does  not  cure.  The  final  result  may 
vary  considerably  even  when  the  same  operative  procedure  has 
been  employed;  i.e.,  in  case  of  suture  of  the  flexor  tendons  of  the 
fingers,  in  one  case  motion  may  be  complete,  while  in  another 
case  there  will  be  entire  inability  to  flex  the  fingers.  The  fingers 
remain  extended,  and  while  capable  of  passive  flexion,  regain 
their  extended  position  as  soon  as  the  flexing  force  is  removed. 
In  the  first  instance  union  of  the  divided  tendons  has  been 
complete  and  suitable  after-treatment  has  freed  the  tendon 
from  adhesions;  in  the  second  instance  union  has  failed  to  take 
place.  In  another  class  of  cases  motion  is  impossible  or  limited 
owing  to  the  adhesions  between  the  divided  tendon,  its  sheath, 
and  the  surrounding  tissues. 

As  the  function  of  the  tendon  consists  in  transferring  the 
muscular  movements  to  its  attachment,  it  is  necessary  that  the 
mobility  of  the  tendon  in  its  sheath  be  absolutely  free.  When  a 
tendon  has  been  divided  the  contractility  of  the  muscle  causes  a 
wide  separation  of  the  divided  ends,  which  is  further  increased 
by  the  unopposed  action  of  the  oppositely  acting  muscles. 
Suturing  unites  the  divided  ends  temporarily  and  favors  union, 
but  only  too  frequently  is  this  disturbed.  The  poor  blood 
supply  causes  slow  union.  On  account  of  the  longitudinal 
direction   of   the   tendon   fibers   the   sutures   readily  tear   out; 


OPERATIONS    UPON    SPECIAL    TISSUES  315 

especially  as  the  contractility  of  the  muscle  causes  considerable 
traction.  This  muscular  contractility  must  be  limited  as  much 
as  possible  by  means  of  snugly  applied  bandages.  The  muscle 
must  be  relaxed  by  approximating  as  closely  as  possible  its 
point  of  origin  and  insertion.  In  lesions  of  flexor  tendons  this 
is  accomplished  by  superflexion,  in  case  of  the  extensors  by 
superextension.  Neighboring  joints  must  be  fixed  by  splint. 
Absolute  immobility  during  the  early  days  of  healing  is  essential 
to  success.  Splints  are  applied  to  the  side  of  the  member 
opposite  the  wound. 

If  infection  has  not  taken  place  it  is  not  necessary  to  change 
the  dressing  until  union  has  occurred,  not  firm  union  perhaps, 
but  of  sufficient  strength  to  allow  of  change  of  dressing.  Union 
is  usually  firm  enough  in  ten  to  fourteen  days  to  permit  this. 

Continuity,  the  first  essential  to  success,  has  then  been  estab- 
lished. If  drainage  has  been  employed  this  is  removed  on  the 
second  to  the  fourth  day  without  disturbing  the  splint.  The 
relation  of  the  parts  must  not  be  disturbed  and  the  same  care  be 
exercised  in  rebandaging  the  parts.  After  the  twenty-first  day 
the  dressing  may  be  gradually  loosened.  The  plastic  exudate 
and  later  the  new  connective  tissue  which  has  united  the  sutured 
ends  and  in  part  surrounds  them  has  also  produced  adhesions  to 
the  surrounding  tissues.  The  newly  cicatrized  point  of  suture 
has  grown  fast  to  the  tendon-sheath,  or  in  the  absence  of  a  sheath 
to  the  surrounding  parts.  This  union  not  infrequently  extends 
to  the  skin  cicatrix,  so  that  on  attempting  active  and  passive 
motion  the  movements  are  found  to  be  restricted,  the  surrounding 
parts  moving  with  the  tendon.  It  is  the  new  cicatricial  tissue 
which  causes  this  fixation  of  the  tendon.  This  must  be  stretched. 
Passive  and  active  movements  accompanied  by  massage  and 
baths,  systematically  carried  out  over  a  period  of  weeks  and 
months,  will  cause  the  scar  tissue  to  stretch  and  render  the 
tendon  freely  movable  in  its  sheath.  If  these  movements  are 
not  carried  out  there  will  result  loss  of  function  of  the  injured 
part.  The  cicatricial  tissue  becomes  old,  firm,  and  nonelastic, 
and  this  can  only  be  remedied  by  further  operation  with  excision 
of  the  scar  tissue.  The  final  result  of  such  secondary  operations 
is  always  doubtful.     Therefore  it  is  essential  first  to  absolutely 


316  OPERATING    ROOM    AND    THE    PATIENT 

fix  the  parts  in  their  jDroper  position  and  later  to  employ  active 
and  passive  motion  to  restore  the  function. 

Complication  by  Suppuration. — If  the  wound  becomes  infected 
or  was  infected  from  the  first  as  in  traumatic  cases  the  result  will 
be  doubtful.  The  tendon  ends  slough  and  direct  union  fails. 
The  large  amount  of  cicatricial  tissue  thrown  out  to  fill  the  gap 
connects  the  ends  only  to  a  limited  degree.  The  extensive 
adhesions  to  the  surrounding  tissues  prevent  a  good  functional 
result.  Cicatricial  contraction  ensues  and  results  in  a  contrac- 
ture of  the  parts  which  it  is  difficult  to  remedy.  Tenosjmovitis 
due  to  infection  may  take  place  and  extensive  sloughing  of  the 
tendon  ensue. 

Treatment. — The  wound  is  left  entirely  open  and  a  mildly 
antiseptic,  freeh^  evaporating  absorbent  dressing  applied  and 
changed  several  times  daily.  Sloughing  portions  of  tendon  are 
removed.  When  the  wound  becomes  clean  tenorrhaphy  and 
plastic  operations  for  the  cure  of  the  disability  are  undertaken. 

Muscular  suture  is  similar  to  tendon.  The  same  rules  apply 
in  relaxation  of  the  muscle.  Bandaging  and  position  aid  in 
controlling  spasmodic  movements.  Union  is  more  rapid  on 
account  of  the  better  blood  supply.  There  is  more  effusion  of 
blood  and  usuallj"  a  hematoma  forms.  If  several  muscles  are 
involved  the  hematoma  may  be  quite  extensive,  and  drainage 
be  made  necessary.  Passive  and  active  movements  are  essential, 
for  atrophy  is  marked  and  rapid,  partly  on  account  of  inaction 
but  more  on  account  of  the  section  of  many  small  nerves.  In 
from  eight  to  ten  daj^s  light  massage  and  electricity  should  be 
used.  In  three  weeks  slight  voluntary  movements  should  be 
encouraged  and  gradually  increased. 

Tenotomy  and  Myotomy. — In  the  treatment  of  contractures  the 
endeavor  is  just  the  opposite  from  tendon  and  muscle  suturing, 
for  here  it  is  desired  to  produce  a  decided  gap  to  be  filled  in  with 
cicatricial  tissue  connecting  the  partially  or  completely  severed 
ends.  This  is  favored  by  the  growth  of  connective  tissue  from 
the  tendon  sheath  and  surrounding  tissue  into  the  organizing 
blood  clot  between  the  tendon  ends.  If  one  allows  tenotomy  or 
myotomy  to  be  followed  by  the  correction  of  the  mal-position  and 
the  fixation  of  the  member  in  the  corrected  position,  there  is 


OPERATIONS    UPON    SPECIAL    TISSUES  317 

danger  that  the  too  widely  separated  ends  will  not  undergo  any 
union  at  all,  and  that  each  end  will  only  unite  with  its  tendon 
sheath  or  the  surrounding  tissue,  and  the  muscle  become  func- 
tionless,  the  same  as  after  the  unintentionally  cut  tendon  which 
has  not  been  united  by  suture.  This  is  not  desired.  The  func- 
tion of  the  divided  muscle  should  be  preserved.  The  purpose  of 
the  operation  is  to  artificially  increase  its  length.  To  obviate  the 
danger  of  nonunion,  the  muscle  or  tendon  may  be  only  partiall}'' 
divided  through  a  minute  incision  and  the  remainder  of  the  muscle 
or  tendon  torn  or  stretched,  or  it  may  be  advisable  to  correct  the 
position  five  to  eight  days  following  the  tenotomy  or  myotomy. 
In  the  interval  the  insignificant  skin  wound  has  healed  under  an 
aseptic  dressing  and  new  connective  tissue  has  formed  between 
the  divided  ends  which  guarantees  the  definite  bridging  over  of 
the  space.  By  the  judicious  use  of  appropriate  orthopedic 
apparatus  this  new  tissue  is  stretched  to  the  proper  length. 
Four  weeks  rest  in  the  corrected  position  is  usually  sufficient. 
Function  is  then  restored  by  electricity,  massage,  passive  and 
active  motion  and  the  use  of  suitable  orthopedic  apparatus. 

Tuberculous  Tenosynovitis. — At  the  operation  the  tendon 
sheath  has  been  opened  widely  and  perhaps  considerable  of  it 
removed.  In  such  cases,  if  asepsis  is  successful  and  all  diseased 
tissue  has  been  removed,  there  will  result  adhesions  between  the 
tendon  and  the  surrounding  tissues,  especially  the  skin,  which  will 
interfere  with  the  function  for  a  long  time.  These  adhesions 
are  especially  firm  at  the  point  where  the  drain  emerged.  The 
overlying  skin  follows  the  movements  of  the  tendon.  The  great 
mobility  of  the  skin  allows  of  some  functional  result,  with  which 
we  may  be  satisfied  if  a  recurrence  of  the  disease  does  not  take 
place.  The  use  of  the  parts  frees  the  adhesions  gradually.  Too 
early  movements  predispose  to  a  recurrence  of  the  disease. 
Electricity  and  massage  should  be  employed  to  prevent  atrophy. 

Dupuytren's  Contracture. — Following  complete  excision  of  the 
contracted  fascia,  the  hand  and  wrist  is  splinted  with  the  affected 
finger  in  extension.  The  parts  are  kept  quiet  for  seven  days 
when  the  sutures  are  removed  and  the  finger  gently  flexed. 
The  splint  may  be  left  off  in  the  daytime  and  applied  at  night  for 
a  week  longer  when  it  may  be  entirely  discarded.     The  success  of 


318  OPERATING    ROOM    AND    THE    PATIENT 

the  operation  depends  on  complete  excision  of  the  contracted 
fascia,  strict  asepsis  and  early,  persistent  and  methodic  massage. 
If  the  scar  is  exposed  to  injury  through  the  patient's  occupation 
a  leather  palm  protector  should  be  worn. 

Circulatory  disturbance  and  severe  pain  may  necessitate  the 
early  removal  of  the  splint  to  allow  of  slight  flexion  of  the  finger. 
If  this  has  been  done  the  extended  position  should  be  again 
resumed  in  twenty-four  hours. 

Contracture  of  the  Finger-joints. — The  most  important  con- 
sideration in  these  contractures  relates  to  the  condition  of  the 
tendons.  With  adhesions  in  the  sheaths  of  the  tendons  the 
condition  of  the  joints  is  of  more  importance,  since,  even  if  the 
motion  of  these  were  restored,  the  fingers  would  be  compara- 
tively useless. 

In  cases  of  threatened  stiffness  of  the  fingers  it  is  important  to 
provide  for  a  useful  position  of  the  finger  by  avoiding  the  use  of 
straight  splints  and  employing  such  means  of  support  during  the 
healing  process  as  shall  prevent  stiffening  in  the  straight  position 
but  rather  favor  partial  flexion.  The  adjoining  uninjured  finger 
may  serve  as  a  splint  to  which  the  injured  finger  may  be  secured, 
or,  with  proper  dressings  applied,  the  finger  may  be  supported 
by  a  mass  of  gauze  in  the  partially  clenched  fist  and  bandaged 
in  this  position.  With  fingers  ankylosed  in  the  straight  position 
attempts  may  be  made  to  correct  the  position  under  an  anes- 
thetic. Similarly,  in  the  flexed  position,  correction  may  be  at- 
tempted if  the  function  of  the  tendons  has  not  been  impaired, 
with  the  hope  of  obtaining  voluntary  motions  after  a  period  of 
treatment  by  passive  movements  and  massage.  The  half -flexed 
position  during  the  healing  process  gives  better  opportunity  for 
passive  movements  than  either  full  extension  or  full  flexion. 

Habitual  contractures  are  observed  in  those  following  certain 
occupations,  such  as  coachmen.  The  constant  flexion  of  the 
fingers  leads  to  a  shortening  of  the  flexor  tendons  and  palmar 
fascial  bands,  and  to  adhesion  of  the  synovial  folds  within  the 
joints. 

Cicatricial  contractures  are  very  frequent  after  burns  and  other 
injuries  of  the  fingers  and  hand.  When  large  traumatic  defects 
of  the  skin  exist,  the  skin  transplantation  method  of  Thiersch 


OPERATIONS    UPON    SPECIAL    TISSUES  319 

may  be  tried.  The  result,  as  far  as  restoration  of  function  is 
concerned,  is  not  very  satisfactory.  When  applicable,  the  method 
of  trans'plantation  of  shin  flaps  with  a  'pedicle  is  to  be  preferred. 
The  flap  may  be  taken  from  the  chest  wall  or  other  available 
region,  according  to  the  location  of  the  defect. 

OPERATIONS  UPON  THE  VASCULAR  SYSTEM. 

The  prominent  complications  are  secondary  hemorrhage  and 
disturbances  of  circulation.  The  larger  the  vessel  involved,  the 
greater  the  danger  of  these  complications.  Prevention  does 
much  to  guard  against  secondary  hemorrhage,  such  as  care  in 
the  application  of  the  ligature,  or  if  this  is  impossible  clamps 
left  in  situ  and  packed  around  with  gauze.  In  venous  oozing  a 
tight  packing  is  used.  In  spite  of  all  efforts  at  prevention, 
hemorrhage  may  occur  as  a  result  of  a  ligature  cutting  through  a 
diseased  vessel  wall;  or  infection  may  result  in  secondary  hemor- 
rhage. If  infection  occurs  the  patient  must  be  constantly 
watched  and  the  attendant  instructed  to  exert  digital  pressure 
directly  in  the  wound  on  its  occurrence.  If  clamps  are  employed 
they  are  allowed  to  remain  in  place  for  forty-eight  hours.  The 
patient  must  be  kept  quiet  in  order  to  avoid  any  disturbance 
of  the  clamps.  After  the  clamps  have  been  removed  if  there 
is  no  renewal  of  the  hemorrhage  a  small  strip  of  gauze  may 
be  led  down  to  the  suspected  place  and  the  wound  closed  for 
the  most  part  by  secondary  sutures. 

If  the  hemorrhage  has  been  controlled  by  tight  packing,  this 
should  not  be  disturbed  for  from  two  to  four  days.  Its  removal 
should  be  accomplished  carefully  in  order  to  avoid  a  renewal  of 
the  bleeding.     A  renewed  bleeding  calls  for  a  second  packing. 

Lateral  ligature  of  a  vein  or  artery  may  be  packed  as  an  addi- 
tional support  to  the  wounded  vessel  wall.  As  a  rule,  however, 
this  is  undesirable. 

Disturbances  of  circulation  depend  upon  the  size  of  the  vessel 
and  the  site  of  the  ligature.  In  moderately  sized  and  small 
vessels  no  disturbances  are  noted.  Following  the  ligature  of  the 
external  iliac,  femoral,  axillary,  or  subclavian  artery  in  the  normal  ' 
state,  the  collateral  circulation  is  usually  sufficient  to  carry  on 
the  nutrition  of  the  parts.     In  arteriosclerotic  conditions  danger 


320  OPERATING    ROOM    AND    THE    PATIENT 

of  gangrene  is  imminent,  due  to  the  weak  heart  action  and  lack 
of  elasticity  of  the  arterial  wall.  The  larger  the  vessel  and  the 
nearer  to  the  heart,  in  such  cases,  the  greater  the  danger.  A 
prognosis  can  onl}^  be  given  after  the  case  has  been  studied  for 
some  days.  For  example,  ligature  of  the  common  carotid  is 
followed  by  no  ill  effect  in  some  cases,  while  in  others  sudden 
death  results,  and  in  still  others,  brain  softening.  Faintness,  im- 
paired vision  or  hemiplegia  may  be  recent,  iinmediate  or  remote 
effects  of  the  ligation.  Following  ligation  of  the  innominate  or 
subclavian  artery  muscular  weakness,  stiffness  and  numbness 
persist  for  some  time.  Pain  due  to  inclusion  of  nerve  fila- 
ments in  the  ligature,  injury  to  the  pleura,  phrenic  nerve  or 
subclavian  vein  occasionally  occur  due  to  accident  during  the 
operation. 

Symptoms  of  disturbed  circulation  become  evident  at  first  in 
the  most  distal  part  of  the  extremity  involved.  The  surface 
becomes  cold,  pulsation  in  the  terminal  artery  (radial,  dorsalis 
pedis,  posterior  tibial)  is  absent  or  only  thread-like.  Sensation 
is  blunted.  There  may  develop  paresthesia,  formication,  and  in 
some  cases  severe  neuralgia.  Should  the  collateral  circulation 
prove  equal  to  the  task  of  reestablishing  the  balance  of  the  circu- 
lation, the  above  symptoms  gradually  subside.  If,  on  the  other 
hand,  the  collateral  circulation  is  insufficient,  gangrene  of  at 
least  a  part  of  the  limb  will  ensue.  This  is  marked  by  an  in- 
crease of  the  symptoms,  the  rapidity  of  which  is  controlled  by 
the  extent  of  the  collateral  circulation.  There  is  edematous 
swelling,  loss  of  sensation,  the  skin  becomes  bluish  in  places,  and 
gangrene  extends  from  the  distal  portion  upward  until  a  point 
is  reached  where  the  circulation  is  sufficient  not  only  to  supply 
nutrition  but  to  successfully  combat  the  spreading  septic  proc- 
ess secondary  to  gangrene. 

Treatment  does  not  have  any  influence.  Light  diet  is  indi- 
cated. Sufficient  morphin  is  given  to  keep  the  patient  comfort- 
able. The  parts  should  be  enveloped  in  cotton  and  kept  warm. 
Absolute  rest  in  bed  should  be  enforced.  The  equilibrium  of 
the  circulation  should  be  maintained  as  nearly  as  possible  by 
keeping  the  part  in  a  horizontal  position  or  but  slightly  elevated. 
High  elevation  or  allowing  the  part  to  become  dependent  is  to 


OPERATIONS    UPON    SPECIAL    TISSUES  321 

be  avoided.  Care  should  be  exercised  in  applying  the  dressings 
that  no  pressure  be  used. 

Varicosities  of  the  Saphenous  Veins. — Following  Trendelen- 
burg's operation  (ligation  of  the  internal  saphenous  at  the  saph- 
enous opening)  or  excision,  the  patient  is  kept  in  bed  with  the 
limb  snugly  bandaged  and  kept  slightly  elevated  for  seven  to 
ten  days  when  the  sutures  are  removed,  the  limb  rebandaged  and 
the  patient  allowed  to  walk  about.  Snug  supporting  bandages 
should  be  applied  daiily  for  several  weeks.  The  bandage  is  re- 
moved at  night  and  reapplied  in  the  morning.  It  should  extend 
from  the  base  of  the  toes  to  the  knee.  Complicating  eczema  and 
ulcers  are  treated  by  strapping  with  adhesive  plaster.  These 
ulcerated  areas  are  much  benefited  if  exposed  for  a  few  hours 
daily  to  direct  sunlight. 

In  impending  gangrene  following  high  ligation  of  the  femoral 
vein,  vertical  suspension  of  the  limb  is  indicated.  The  artery 
should  not  be  tied,  as  was  formerly  taught.  There  are  marked 
congestion  and  edematous  swelling.  The  superficial  veins  be- 
come dilated  and  the  power  of  resistance  of  the  parts  greatly 
lowered.  The  limb  should  be  bandaged  to  support  the  super- 
ficial circulation.  If  these  means  fail  amputation  must  be  re- 
sorted to.  If  gangrene  does  not  occur  massage  and  passive 
movements  are  to  be  employed  for  the  edema.  Several  months 
elapse  before  the  edema  subsides,  and  in  some  cases  swelling  may 
persist  indefinitely.  This  is  also  true  in  case  of  the  subclavian 
and  axillary  veins. 

In  the  removal  of  small  varices  no  disturbance  of  circulation 
is  apparent. 

Thrombosis  and  Embolism. — The  thrombus  organizes  as  soon 
as  the  next  collateral  branch  is  reached,  in  case  infection  is  not 
present.  Thrombosis  will  occasionally  ensue  when  no  injury 
has  been  done  to  the  vein  involved.  Massage  of  the  limb  tends 
to  prevent  their  formation  by  maintaining  the  equilibrium  of  the 
circulation.  The  swelling  may  not  become  apparent  until  the 
patient  walks  about.  When  thrombi  are  suspected  rest  should 
be  enforced  to  prevent  embolism. 

Aneurysm. — Following  operation  for  aneurysm  there  is  danger 
of  embolism.     Pulsation  disappears  immediately  after  proximal 


322  OPERATIXG    ROOM    AXD    THE    PATIENT 

ligation,  slowly  after  distal  ligation;  it  is  present  after  arterio- 
plasty.  The  aneurysmal  tumor  shrinks.  Rest  must  be  enforced 
for  several  weeks  after  ligation.  The  blood  pressure  should  be 
kept  low.  Following  ligature  operations  there  is  danger  of 
secondary  hemorrhage  due  to  the  ligature  cutting  through  the 
diseased  vessel  wall. 

Following  Matas  arterioplasty  the  hollow  on  the  surface  left 
by  the  obliteration  of  the  aneurysm  sac  is  filled  with  gauze  and 
the  parts  overlying  and  in  the  neighborhood  of  the  operation  are 
supported  by  cardboard  splints  accurately  molded  to  the  parts 
and  exerting  even  elastic  pressure.  The  entire  limb  in  the  case 
of  an  extremity  is  loosely  bandaged  with  cotton  to  maintain 
the  temperature.  The  parts  are  kept  at  absolute  rest  by  means 
of  splints,  a  long  posterior  splint  for  the  lower  extremity,  a 
molded  plaster  splint  for  the  upper  extremity.  The  fingers  or 
toes  are  left  exposed  to  watch  the  circulation.  The  extremity  is 
kept  snugly  bandaged  for  ten  days  when  all  dressings  and  sutures 
are  removed.  Usually  the  limb  will  requu'e  rebandaging  owing 
to  loosening  of  the  bandages  several  times  before  the  tenth  day. 
In  the  upper  extremity  slight  movements  are  permitted  after 
the  tenth  day  and  these  may  be  gradually  increased  until  at  the 
end  of  three  weeks  full  use  of  the  extremity  is  allowable.  In  the 
lower  extremity  the  period  of  rest  should  be  longer,  two  to  three 
weeks  before  much  moA'ement  is  allowed.  Bandaging  is  desir- 
able to  support  the  circulation. 

Complications. — Infection  is  rare.  Secondary  hemorrhage  un- 
common. The  chief  danger  is  from  embolism  which  if  the  col- 
lateral circulation  is  not  sufficient,  will  result  in  gangrene 
requiring  amputation. 

OPERATIONS  UPON  THE  LYMPHATIC  SYSTEM. 

Lymphangitis  (see  p.  271). 

Lymphadenitis  (see  p.  272). 

Ljonphatic  Edema. — In  cases  m  which  there  is  obstruction  of 
lymphatic  drainage  of  a  part  as  after  axillary  adenectomj^  for 
carcinoma  (p.  428)  a  quite  diffuse  lymphatic  edema  of  the  limb 
may  persist  for  some  months.  This  is  best  overcome  by  frequent 
massage  and  bandaging,  at  least  twice  daily.     The  massage  is 


OPERATIONS    UPON    SPECIAL    TISSUES  323 

employed  gently  from  the  finger  tips  upward  to  the  shoulder. 
As  a  rule  this  form  of  edema  is  quite  easily  pressed  out  of  the 
tissues.  Following  each  massage  the  part  is  snugly  bandaged 
without  too  great  pressure.  Under  treatment  even  severe  cases 
will  subside  in  several  months,  and  may  in  time  completely 
disappear.  In  some  cases,  however,  there  remains  a  more  or  less 
localized  edema  on  the  inner  side  of  the  arm  above  the  elbow 
which  is  particularly  persistent.  Elevation  of  the  affected 
member  aids  lymphatic  return  and  should  be  insisted  upon  as  a 
part  of  the  treatment.  In  persistent  cases  lymphangioplasty  is 
indicated. 

Lymphangioplasty  (Samson  Handley).^ — The  precise  amount 
of  shrinkage  caused  by  this  operation  is  shown  by  careful  meas- 
urements before  and  after  the  operation.  The  massage  and 
bandaging  instituted  for  the  original  condition  (lymphatic 
edema)   should  be  persisted  in. 

Lymphorrhea  may  follow  injury  to  any  large  lymphatic 
channel.  Such  injuries  are  apt  to  occur  in  the  course  of  opera- 
tions on  enlarged  glands,  particularly  in  the  clavicular,  axillary, 
and  inguinal  regions.  Infection  of  the  lymph  channels  may 
follow.  The  lesion  is  characterized  by  a  large  effusion  of  lymph 
necessitating  frequent  change  of  dressings.  The  escape  of  lymph 
may  be  concealed  by  the  wound  discharges.  In  injury  of  larger 
lymph  ducts  there  will  be  profuse  discharge  of  thin,  clear,  yellow- 
ish fluid.  Usually  by  stimulating  the  granulating  process  the 
lymphatic  openings  heal  over,  though  a  considerable  time  may 
elapse  before  final  healing  is  effected.  Sometimes  the  flow  of 
lymph  is  controlled  by  the  simple  pressure  of  the  dressing. 
Pressure  upon  the  wound,  however,  with  this  object  in  view  is 
likely  to  be  followed  by  lymphatic  varix  of  the  tributary  lym- 
phatics. Should  healing  be  delayed  the  wound  may  be  cau- 
terized with  the  thermocautery,  thus  sealing  the  openings  in  the 
lymphatic  vessels.  In  case  a  large  lymphatic  trunk  has  been 
injured  it  may  be  necessary  to  expose  and  ligate  it.  Lymph- 
orrhea may  complicate  compound  fractures. 

Injury  to  the  Thoracic  Duct  (p.  394). 

Lymphangiectasis  occurs  as  a  complication  of  inflammations 

'  Lancet,  Jan.  2,  1909. 


324  OPERATIXG    EOOM    AND    THE    PATIENT 

or  obstruction  from  bandage  and  cicatrices  (lymphatic  varix). 
As  the  trouble  is  an  obstructive  one  excision  is  not  recommended. 
Treatment  such  as  is  used  in  lymphatic  edema  is  first  indicated — 
support,  compression  and  massage.  If  this  is  not  effectual 
lymphangioplasty  or  anastomosis  with  a  neighboring  vein^  is 
recommended. 

Persistent  fistula  following  excision  in  suppurative  adenitis. 
If  the  entire  gland  has-  not  been  removed  a  sinus  will  persist. 
Treatment  of  such  a  sinus  is  unavailing  unless  the  remaining 
gland  tissue  be  removed.  Excision  of  the  tract  and  giaiid  tissue 
is  best.  If  suppuration  is  prolonged  other  glands  in  the  neighbor- 
hood are  apt  to  become  infected. 

Adenectomy  for  Tuberculosis.- — The  patient  should  be  placed 
in  as  hygienic  conditions  as  possible.  Many  excellent  results 
have  been  reported  from  the  use  of  tuberculin  as  a  prophylactic 
against  recurrence.  Persisting  sinuses  are  best  treated  by 
thorough  excision. 

Adenectomy  for  other  causes  (chancroid,  infections)  requires  the 
determination  of  the  exciting  cause  and  the  initiation  of  treat- 
ment for  it. 

OPERATIONS  ON  THE  NERVOUS  SYSTEM. 

Peripheral  Nerves.  Nerve  Resection,  Nerve  Suture,  Nerve 
Anastomosis. — It  is  presupposed  that  healing  has  occurred  with- 
out the  interposition  of  much  intermediate  connective  tissue. 
Centrally  the  sensory  fibers,  distally  the  motor  fibers,  degenerate. 
Fibers  regenerate  from  the  center  to  the  periphery.  The  more 
accurate  the  approximation  of  the  severed  ends,  the  more  rapid 
the  regeneration  will  be.  The  position  of  the  parts  should  for 
fourteen  days  following  operation  be  such  that  there  is  no  ten- 
sion on  the  united  nerve.  At  this  time  mild  galvanism,  f  aradism 
and  massage  should  be  employed  daily  to  avoid  atrophy  and 
contraction  of  the  paralyzed  muscles.  Passive  movements, 
specially  constructed  splints,  and  elastic  apparatus  should  be 
used  to  counteract  the  opposing  muscles.  Atrophy,  however, 
cannot  be  entirely  prevented.     The  daily  use  of  the  galvanic  and 

^  Godlee  and  Manson,  Clinical  Society  Transactions,  London,  vol.  xxxv,  p.  209. 


OPERATIONS    UPON    SPECIAL    TISSUES  325 

faradic  currents  aids  also  in  the  study  of  the  process  of  regenera- 
tion and  therefore  in  the  prognosis.  Electric  contractility  at 
first  lessens  and  in  from  seven  to  twelve  days  disappears  en- 
tirely. Following  this  the  reaction  of  degeneration  occurs, 
while  later  the  reaction  becomes  gradually  normal,  the  galvanic 
reaction  appearing  first,  then  the  faradic.  It  is  possible  that 
active  movements  may  occur  before  electric  contractility  is 
present.  Usually  about  nine  months  elapse  before  a  functional 
result  is  obtained.  The  nearer  the  periphery  the  nerve  has  been 
cut,  the  more  rapid  the  return  to  normal.  Sensation  returns 
first,  often  very  early.  In  such  a  case  a  recovery  may  occur  in 
six  months.  At  times  quite  astonishing  results  are  obtained. 
The  author  has  completely  sectioned  the  musculo-spiral  nerve 
in  removing  a  fibroneuroma  and  had  a  return  of  function  on  the 
thirty-third  day,  whereas  there  had  been  total  musculo-spiral 
paralysis  for  three  months  before  the  operation. 

Course  following  Nerve  Anastomosis  for  Facial  Paralysis.- — 
Nerve  disturbances  will  depend  upon  which  nerve  has  been 
selected  for  the  anastomosis.  If  the  spinal  accessory  nerve  has 
been  sectioned  there  follows  temporary  inability  to  raise  the  arm 
above  the  horizontal,  drooping  of  the  shoulder  and  partial 
atrophy  of  the  sterno-mastoid  and  trapezius  muscles.  Whether 
the  spinal  accessory  nerve  has  been  sectioned  or  not  associated 
movements  of  the  shoulder  and  face  muscles  commonly  follow 
the  operation  where  regeneration  has  been  effected.  No  definite 
rule  can  be  laid  down  in  this  regard. 

Shoulder  movements  are  not  usually  possible  without  move-' 
ments  of  the  face,  though  coordinate  face  movements  may 
occur  without  shoulder  movements.  Some  cases  do  not  have 
associated  movements.  Once  present,  associated  movements 
are  apt  to  prove  permanent,  though  cases  are  reported  which 
have  learned  to  disassociate  completely  the  voluntary  move- 
ments of  the  face  and  shoulder. 

If  the  hypoglossal  nerve  has  been  used,  section  will  result  in 
paralysis  and  atrophy  of  one-half  of  the  tongue  and  at  first 
difficulty  in  speech  and  swallowing.  For  this  reason  lateral 
anastomosis  is  preferred.  Associated  face  and  tongue  move- 
ments follow. 


326  OPERATIXG    ROOM    AND    THE    PATIENT 

Other  nerves  have  been  employed  and  give  the  expected 
physiologic  complications. 

The  first  result  noted  in  a  successful  case  is  a  return  of  facial 
symmetry,  then  follows  return  of  voluntary  control.  Perfect 
restoration  of  expression  and  emotion  is  not  to  be  expected, 
though  if  the  subject  is  young  the  new  cortical  centers  might  be 
educated. 

The  treatment  is  as  for  nen^e  operations  in  general,  electricity' 
and  massage.  Improvement  may  be  noted  in  from  a  few  weeks 
to  a  few  months,  though  the  extent  of  improvement  may  not 
be  final  for  a  year  or  more. 

Following  suture  of  the  brachial  plexus,  the  forearm  is  supported 
by  a  sling  during  the  period  of  paralysis  to  avoid  strain  on  the 
cords  from  the  weight  of  the  extremity.  In  applying  the 
primary  dressing  the  shoulder  is  brought  forward  and  elevated, 
and  the  neck  inclined  toward  the  injur}-  to  avoid  tension. 
Immobilization  of  the  entire  extremity  and  neck  is  maintained 
for  three  weeks.  Regeneration  is  slower  than  after  injury  to 
more  superficial  nerve  trunks  and  complete  restoration  to 
function  is  rare. 

The  after-treatment  in  cases  of  paralysis  caused  by  pressure 
from  callus,  cicatricial  tissue,  exudate,  and  tumor,  is  along  the 
same  lines,  the  cause  having  been  removed. 

Nerve-stretching  depends  for  its  success  upon  the  removal  of 
pressure  from  exudate.  If  the  stretching  has  been  thoroughly 
done,  temporary  partial  paralysis  will  result. 

Needling  the  nerve  produces  temporary  partial  paralysis. 

Following  neurotomies  and  neurectomies  for  painful  condi- 
tions the  disappearance  of  pain  is  usually  immediate,  though 
in  rare  cases  the  pain  may  persist  for  a  few  days  and  necessitate 
the  use  of  morphin.  It  often  follows  that  the  resulting  anes- 
thesia is  limited  to  a  much  smaller  area  than  was  expected  and 
feeling  may  return  without  being  accompanied  by  the  original 
neuralgia.  Many  patients  are  permanently  cured,  while  in 
others  there  is  rapid  recurrence  of  the  pain.  Trophic  disturb- 
ances may  follow  nerve  suture.  Edema  is  treated  by  massage 
and  supporting  bandages;  dryness  of  skin  by  warm  baths  and 
vaselin;   disturbances  of  circulation  by  elevation  and  massage. 


OPERATIONS    UPON    SPECIAL   TISSUES  327 

Following  neurectomy  of  the  second  branch  of  the  trigeminus 
trophic  keratitis  may  develop.  This  is  treated  by  protecting 
the  eye  with  cotton,  the  instillation  of  atropin,  and  the  usual 
eye  treatment. 

OPERATIONS  UPON  THE  SPINAL  CORD  AND  POSTERIOR  NERVE 

ROOTS. 

Underlying  Principles. — Surgically  the  spinal  cord  is  divided 
into  the  cord  proper,  composed  of  nonneurilemmatous  elements 
beginning  above  at  a  line  between  the  articular  surfaces  of  the 
atlas  and  the  condyles  of  the  occipital  bone  corresponding  to 
the  decussation  of  the  pyramidal  tracts  and  ending  at  the  twelfth 
dorsal  vertebra;  the  cauda,  composed  of  neurilemmatous  ele- 
ments, and  the  anterior  and  posterior  nerve  roots,  nonneurilem- 
matous in  the  cord  and  neurilemmatous  outside  the  cord. 

The  value  of  operative  interference  in  injuries  or  diseases  of 
the  spinal  cord  depends  primarily  upon  the  character  of  the 
structures  involved.  Regeneration  is  possible  only  in  those 
portions  of  the  cord  in  which  neurilemma  is  present;  that  is, 
in  the  spinal  nerve  roots  external  to  the  cord  proper  and  in  the 
Cauda.  Regeneration  never  occurs  in  the  spinal  cord  proper. 
What  does  at  times  occur  is  that  some  of  the  work  of  a  given 
segment  may  be  taken  up  in  part  at  least  by  the  segment  above 
and  below  the  one  affected  through  already  existing  anasto- 
moses between  the  spinal  nerves  outside  the  spinal  cord  itself. 
These  facts  are  the  fundamental  principles  upon  which  must 
rest  all  operative  interference.  A  knowledge  of  them  combined 
with  an  exact  knowledge  of  the  anatomy  and  physiology  of  the 
nerve  roots,  the  cauda  and  the  cord  proper  with  an  exact  knowl- 
edge of  the  pathology  of  the  lesion  is  essential.  The  most  im- 
portant underlying  principle  is  that  where  there  is  neurilemma 
regeneration  occurs;  where  there  is  no  neurilemma  regeneration 
is  impossible.  Whatever  structure  is  involved  degeneration  is 
certain  but  only  in  structures  containing  neurilemma  may 
regeneration  be  expected. 

Knowing  these  fundamental  facts,  we  can  state  with  a  fair 
degree  of  exactitude  what  may  be  expected  or  accomplished  in 
the  treatment  of  given  lesions.     If  the  lesion,  traumatic  or  other- 


328  OPERATIXG    ROOM    AND    THE    PATIENT 

wise,  destroys  the  spinal  structure  itself,  -^-hatever  damage  has 
been  inflicted  to  the  cord  by  it  is  permanent,  though  some 
improvepaent  of  symptoms  may  be  expected  through  already 
existing  nerve  anastomoses.  There  is  no  anatomic  proof  of 
cord  regeneration.  All  experimental  studies  disprove  it.  The 
most  that  has  been  observed  is  the  beginning  gro\vth  of  nerve- 
fiber  in  the  scar  itself  or  in  the  uninjured  dura,  both  devoid  of 
anj"  functional  value.  Our  hope  of  better  results  in  such  cases 
is  through  already  existing  nerve  anastomoses  or  through  making 
such  anastomoses. 


CHAPTER  XII. 
OPERATIONS   UPON   SPECIAL   TISSUES    (Continued). 

Bones  and  Joints. — Chisel  operations.  Osteomyelitis.  Benign  bone 
tumors.  Disturbance  of  function.  Disturbance  of  gro^n-th.  Acute  osteo- 
mye'-tis.  The  after-treatment  of  resection  wounds.  Functional  result. 
Xearthrosis.  Flail-joint.  Ankylotic  union.  The  after-treatment  of  re- 
section of  the  elbow-joint.  After-treatment  of  operations  for  contractures 
and  ankylosis  of  the  hip.  After-treatment  of  resection  of  the  hip  for  tuber- 
culosis. The  functional  results  of  resection  of  the  hip.  After-treatment  of 
arthrotomy  for  detached  semilunar  cartilage  or  joint  mice.  Functional 
results  of  resection  of  the  knee-joint.  After-treatment  of  resection  of  the 
knee-joint.  Partial  resection.  Result  of  resection  of  the  knee-joint. 
Tarsectomy.  Ogston's  operation.  Contracture  at  the  astragalotarsal  joint. 
Talipes  equinus  operations.  Lisfranc's  operation.  The  after-treatment  of 
fractures.  Late  complications  of  fractures.  The  after-treatment  of  frac- 
tures treated  operatively.  Impacted  fracture  of  the  neck  of  the  femur. 
Fracture  of  the  patella.  Amputations  and  disarticulations.  General  rules. 
Stay  in  bed.  Care  of  the  wound.  Drainage.  Shock.  Infection.  Necro- 
sis of  the  flaps.  Bone  necrosis.  Thrombosis  and  embolism.  The  cicatrix. 
Painful  condition  of  the  stump.  Bandaging  of  the  stump.  Cases  in  which 
primary  suturing  is  done.  Traumatic  cases.  Stump  dressing.  Shock. 
Cases  whose  condition  is  so  serious  that  no  immediate  operative  intervention 
can  be  employed.  Cases  in  which  no  primary  suturing  is  done.  Senile 
gangrene.  Operations  through  or  near  the  shoulder  girdle.  Amputations 
below  the  shoulder.  Amputations  below  the  elbow.  Amputations  through 
or  near  the  hip-joint.  Amputations  through  the  thigh.  Amputations  of 
the  toes  or  forefoot.  Amputations  below  the  knee.  Prosthesis.  Hahux 
valgus.     Osteotomy  of  the  tibia  for  bow-legs.     Osteotomy  for  genu  valgum. 

OPERATIONS  UPON  BONE. 
Chisel   Operations    (Osteomyelitis.     Benign   Bone    Tumors). — 

In  operations  in  vhich  the  chisel  has  been  used  there  results  a 


OPERATIONS    UPON    SPECIAL    TISSUES  329 

cavity  in  the  bone  which  is  slowly  filled  by  granulation.  Gener- 
ally speaking,  the  skin  wound  is  closed  except  for  a  small  open- 
ing to  permit  the  emergence  of  the  packing  strip.  The  healing 
process  is  much  delayed  on  account  of  the  unyielding  bony 
walls.  To  hasten  healing  in  the  case  of  aseptic  cavities,  if  skin- 
grafting,  flap  operations,  bone  chips,  sponges,  Moorhoff's  bone 
wax  or  a  Schede  clot  has  been  the  method  used  the  wound  will 
have  been  closed  completely  and  will  be  treated  as  a  wound 
healing  by  primary  intention.  If  infection  occurs  it  becomes 
necessary  to  open  the  wound,  cleanse  and  pack  it.  In  cavities 
treated  by  the  open  method  the  packing  should  be  renewed 
every  four  to  six  days,  each  time  using  a  smaller  packing.  The 
discharge  from  such  wounds  is  always  free.  The  healing  proc- 
ess may  take  two  to  three  weeks  or  three  to  six  months,  accord- 
ing to  the  size  of  the  cavity  and  the  disease  for  which  the  opera- 
tion was  done.  By  reason  of  the  large  amount  of  discharge  the 
general  system  suffers  and  anemia  may  result.  Such  patients 
should  be  out  of  bed  and  in  the  fresh  air  as  soon  as  and  as  much 
as  possible.  To  accomplish  this,  various  forms  of  apparatus  will 
be  necessary.  Following  operations  for  osteomyelitis  amyloid 
degeneration  of  the  viscera  may  complicate  the  after-treatment 
on  account  of  the  long-continued  suppuration.  Such  patients, 
being  much  weakened  by  the  long-continued  discharge,  are 
predisposed  to  tuberculous  infection. 

In  cases  which  have  been  drained  the  skin  becomes  adherent 
to  the  bone.  In  cases  which  heal  by  primary  union  the  cicatrix 
may  at  first  be  adherent  to  the  bone,  but  becomes  loosened  in 
time.  An  adherent  cicatrix,  unless  painful,  is  not  important  in 
operations  upon  an  extremity.  Occurring  on  the  face  it  may  be 
very  deforming.  The  treatment  consists  in  massage,  and  if  this 
fails  a  secondary  plastic  operation  may  be  done.  Such  cica- 
trices occurring  over  the  tibia  are  always  sources  of  irritation 
to  the  patient.  They  are  easily  injured,  and  break  down, 
causing  ulcers.  Such  a  scar  should  be  protected.  A  plastic 
operation  may  be  done  to  bring  healthy  skin  over  the  bony 
prominence.  Persistent  fistula  is  a  common  sequel  of  inflamma- 
tory bone  disease. 

Disturbance  of  Function. — Function  of  the  part  may  be  greatly 


330  OPERATING    ROOM    AND    THE    PATIENT 

disturbed,  and  an  apparatus  may  .be  necessary  until  new  bone 
has  replaced  the  lost  substance.  In  healthy  patients  new  bone 
forms  quickly  and  the  support  is  not  required  very  long. 

Disturbance  of  Growth. — This  usually  results  from  the  disease, 
not  from  the  operation.  If  the  epiphysis  itseK  is  diseased  the 
amount  of  shortening  will  depend  upon  the  age  of  the  patient. 
This  causes,  in  the  case  of  the  forearm  and  leg,  a  bowing  when  one 
bone  is  involved  and  the  other  has  remained  normal. 

Acute  Osteomyelitis. — ^Fever  may  continue  in  spite  of  drainage. 
This  means  that  a  lymphostatic  infection  has  occurred,  or  that 
the  entire  focus  has  not  been  removed.  In  the  latter  case  the 
fever  will  not  subside  until  the  cavity  has  been  cleared  of  all 
septic  products.     Vaccine  therapy  is  usually  indicated. 

The  After-treatment  of  Resection  Wounds. — The  parts  are  to 
be  enveloped  in  copious  dressings  of  aseptic  gauze.  If  drainage 
has  been  employed,  these  should  be  specially  thick  in  the 
neighborhood  where  the  tubes  emerge.  The  copious  dress- 
ings, reinforced  by  thin  basswood  or  pasteboard  splints,  which 
should  extend  beyond  the  next  adjacent  joint  and  be  secured  in 
position  by  starched  gauze  (crinoline)  bandages,  first  wetted 
and  then  applied  will  secure  sufficient  immobilization  of  the 
parts  for  the  first  few  weeks  at  least,  without  the  aid  of  plaster 
of  Paris.  The  ordinary  rules  governing  redressing  should  be 
followed. 

If  all  goes  well  a  large  resection  wound  may  heal  by  primary 
union,  except,  in  cases  in  which  drainage  is  employed,  the  points 
where  the  drains  emerge.  Even  in  the  knee-joint  no  more  time 
is  occupied  in  uncomplicated  cases  than  is  necessary  for  recovery 
from  a  fracture. 

As  the  wound  approaches  complete  healing,  the  surgeon's 
chief  efforts  should  be  directed  toward  securing  the  desired 
functional  result.  In  the  lower  extremity  solid  union  is  to  be 
obtained,  and  with  this  in  view,  a  fixed  form  of  dressing,  such  as 
will  permit  the  application  of  aseptic  measures  and  at  the  same 
time  completely  immobilize  the  parts,  is  to  be  applied.  The 
bracketed  splint  (Fig.  171),  employed  in  connection  with  a 
plaster-of-Paris  casing,  serves  the  purpose  admirably. 

In  the  case  of  the  upper  extremity,  if  a  subcapsular  and  sub- 


OPERATIONS    UPON    SPECIAL    TISSUES  331 

periosteal  resection  has  been  possible,  not  much  difficulty  will 
be  experienced  in  obtaining  an  artificial  joint  (nearthrosis) . 
The  new  bone  is  molded  into  shape  and  even  articular  extremi- 
ties may  form.  Passive  motion  in  the  normal  range  of  the  limb 
will  assist  in  the  molding  process.  The  synovial  membrane 
resumes  its  function.  In  due  time  active  movements  supple- 
ment those  of  a  passive  character.  Atrophy  of  the  muscles 
resulting  from  nonuse  is  to  be  treated  first  by  the  galvanic 
current,  and  subsequently  by  faradization. 

When  it  is  found  impossible  to  preserve  the  synovial  capsule 
and  periosteum,  an  artificial  joint  may  still  be  secured.  The 
perisynovial  connective  tissue  seems  to  assume  the  function  of 
the  synovial  membrane.  Aseptic  healing  materially  aids  in 
producing  a  nearthrosis,  even  when  no  passive  movements  are 
made.  But  flail-like  joints  may  result  from  excessive  mobility, 
the  joint  permitting  movements  in  all  directions  like  a  flail. 
This  condition  may  arise  from  injury  to  important  muscles  by  the 
incisions,  defective  preservation  of  the  periosteum,  severe  and  pro- 
longed suppuration,  the  removal  of  too  much  bone  and  excessive 
passive  movements  during  the  after-treatment,  and  insufficient 
stimulation  of  the  muscular  apparatus,  paralysis  of  the  latter 
from  nerve  injury,  and  paresis  of  the  same  from  want  of  use. 

In  case  of  the  elbow-joint  a  flail-like  joint  is  of  not  infrequent 
occurrence  after  resection  for  tuberculous  disease.  Under 
these  circumstances  it  is  recommended  to  attempt  to  secure 
bony  ankylosis  in  a  proper  position  (Billroth). 

Solid  or  ankylotic  union  must  be  secured  at  the  knee  and 
ankle;  and  even  at  the  hip  it  is  not  a  great  disadvantage.  Good 
functional  results  have  been  obtained,  however,  with  an  artificial 
hip-joint.  Whether  solid  union  is  intended  or  not,  in  case  of 
its  occurrence,  the  limb  is  to  be  placed  in  a  position  most  con- 
venient for  use,  i.e.,  the  elbow  at  a  right  angle  and  the  knee  in 
the  extended  position. 

During  the  period  of  childhood  every  effort  should  be  made  to 
preserve  the  epiphyseal  cartilages  in  resection  of  the  joints. 
Injury  of  these  structures,  with  the  enforced  rest  necessary  in 
resection,  leads  to  lessened  longitudinal  growth  of  the  bone  and 
consequent  relative  shortening  of  the  limb. 


332 


OPERATING    ROOM    AND    THE    PATIENT 


The  After-treatment  of  Resection  of  the  Elbow-joint. — The 

arm  is  to  be  thickly  enveloped  ^vith  aseptic  gauze  dressing  and 
aseptic  cotton-wool  and  placed  at  first  on  a  right-angled  wire 
splint,  or  a  fenestrated  plaster-of -Paris  splint  may  be  employed. 
If  a  movable  j  oint  is  aimed  at,  the  use  of  an  open- wire  frame  sus- 
pended in  an  easy  position,  ■^'ith  bandage  material  stretched 
across  from  side  to  side,  will  be  indicated.  T\Tien  total  resection 
is  performed,  under  which  circumstances  bony  union  of  the  sawed 
surfaces  gives  the  most  useful  arm,  a  splint  Avhich  will  keep  the 
parts  immobile,  and  at  the  same  time  permit  access  for  dressing 
purposes,  is  to  be  used.     The  form  of  splint  shown  in  Fig.  167  is 


Pig  1(37. — Plaster  bridge  elbow  splint.  For  the  after-treatment  of 
resection  of  the  elbow-joint.  Only  the  parts  connected  together  by  the 
"■  bridge "'  are  of  plaster  of  Paris.  The  remainder  is  simple  bandage  material 
retaining  the  dressings  in  position.      (^Fowler's  Surgery.) 

very  useful.  It  is  of  plaster  of  Paris  and  embraces  the  arm  and 
forearm  only,  with  a  comiecting  "bridge"  on  the  anterior  surface. 
A  number  of  turns  of  plaster-of-Paris  bandage  encircle  the  fore- 
arm and  arm  alternately,  the  bridge  being  formed  of  the  same 
bandage  as  it  passes  to  and  fro  from  the  forearm  to  the  arm. 

As  a  rule,  the  patient  may  leave  the  bed  after  the  first  week. 
In  the  movable  joint  cases  daily  passive  movements  in  the  nor- 
mal directions  may  be  commenced  as  soon  as  healthy  granula- 
tions fill  the  wound.  In  injuries  cicatrization  is  under  way 
in  from  four  to  six  weeks;  in  shot  injuries  the  period  is  longer. 


OPEKATIOXS    UPOX    SPECIAL    TISSUES  '  333 

These  movements  are  to  be  followed  as  soon  as  practicable  by  the 
patient's  voluntary  movements.  These  are  to  be  persisted  in, 
particularly  those  of  flexion,  supination,  and  pronation,  the  arm 
being  held  alongside  the  body  and  slightly  abducted. 

After-treatment  of  Operations  for  Contractures  and  Ankylosis 
of  the  Hip. — An  extension  apparatus  (Fig.  168)  and  a  heavy 
weight,  with  the  thigh  in  abduction,  is  to  be  applied  after  all  of 


Fig.   168. — Combined  extension  and  inclined  plane  for  reduction  of  contrac- 
ture of  the  hip.      (Fowler's  Surgery.) 

these  operations,  and  its  use  continued  until  healing  takes  place. 
After  recovery,  to  prevent  recurrence,  the  patient  should  use 
the  weight  and  pulley  extension  at  night  by  means  of  a  garter, 
laced  well  up  on  the  limb. 

After-treatment  of  Resection  of  the  Hip  for  Tuberculosis. — In 
the  after-treatment  extension  and  abduction  must  be  made  and 
continued  for  some  time,  particularly  in  children.  The  dis- 
charge is  considerable  for  the  first  few  days.  To  facilitate 
dressing  of  the  parts  without  producing  pain,  to  enable  the  nurse 
to  prevent  fecal  matter  and  urine  from  soiling  the  dressings,  and 


334 


OPERATING    ROOM    AXD    THE    PATIENT 


to  relieve  pressure  on  the  sacrum  and  prevent  the  development 
of  bed-sores,  the  limbs  should  be  placed  in  the  position  of  vertical 
suspension  sometimes  employed  in  fracture  of  the  femur  in 
children,  with  the  limbs  abducted,  and  the  sacrum  just  free 
from  the  surface  of  the  bed.  This  position  also  greatly  facili- 
tates the  changing  of  the  dressings,  the  pelvis  being  elevated 
during  this  procedure  by  shortening  the  cord  connecting  the 
foot-piece  to  the  cross-bar  of  the  apparatus  (Fig.  169).     When 


Fig.  169. — Vertical  extension  in  the  after-treatment  of   resection  of  the 
hip-joint  in  children.      (Fowler's  Surgery.) 

the  discharge  is  less  and  the  patient  can  be  moved  without 
great  pain,  extension  in  the  horizontal  position  with  abduction 
is  to  be  made.  Later  on,  during  the  period  of  simple  cicatriza- 
tion, Taylor's  hip  splint  (Fig.  170)  should  be  worn  in  the  daytime 
and  the  patient  encouraged  to  walk.  Extension  by  weight  and 
pulley  is  to  be  kept  up  at  night.  Fistulous  openings  which  lead 
to  tracts  lined  with  tuberculous  granulations   should  be  fre- 


OPERATIONS    UPON    SPECIAL    TISSUES 


335 


quently  curetted,  treated  with  pure  carbolic  acid  and  alcohol, 
and  packed  with  gauze  saturated  with  antituberculous  medica- 
ments. These  will  finally  heal  under  this  treatment  if  all  the 
diseased  bone  has  been  removed  at  the  operation 


Fig.   170. — Taylor's  long  traction  splint  applied.      (Fowler's  Surgery.) 


The  Functional  Results  of  Resection  of  the  Hip. — These  are  now 
conceded,  and  the  value  of  the  operation  is  no  longer  doubted. 
In  some  instances  a  reorganization  of  the  joint  takes  place.     In 


336  OPERATING    ROOM    AND    THE    PATIENT 

others,  the  lesser  trochanter,  covered  with  cartilage,  has  been 
found  resting  in  the  acetabulum,  thereby  forming  a  substitute 
for  the  head.  There  can  be  no  question  that  resection  gives  a 
better  limb  than  the  average  result  obtained  without  operation 
in  the  class  of  cases  in  which  resection  is  indicated  according 
to  the  rules  laid  down.  If  the  operation  is  performed  before 
it  .is  positively  indicated,  it  may  be  performed  unnecessarily; 
the  functional  results  following  cure  by  orthopedic  methods 
would  certainly  be  better  as  regards  the  shortening  and  the 
supporting  strength  of  the  limb.  On  the  other  hand,  in  those 
cases  in  which  the  indications  for  resection  are  present,  the 
longer  it  is  delayed,  the  greater  the  mortality,  the  more  pro- 
nounced the  flail-like  character  of  the  limb,  and  the  greater  the 
amount  of  shortening.  When  the  latter  conditions  are  present 
to  the  extent  of  a  comparatively  useless  limb,  the  result  is  to  be 
attributed  to  the  ravages  of  the  disease  which  required  such  an 
extensive  removal  of  bone,  and  not  to  the  operation. 

After-treatment  of  Arthrotomy  for  Detached  Semilunar  Cartilage 
or  Joint  Mice. — The  limb  is  immohilized  on  a  posterior  splint, 
with  lateral  splints  of  light  basswood,  or  put  up  in  plaster  of 
Paris  for  a  week,  after  which  the  ordinary  gauze  dressings  suf- 
fice to  restrain  the  movements  of  the  joint  as  much  as  necessary. 
The  patient  should  be  encouraged  to  move  the  limb  as  much 
as  possible  after  ten  days  have  elapsed.  Should  there  be  a 
tendency  to  restriction  of  flexion,  this  should  be  corrected  by 
passive  movements  and  massage. 

The  Functional  Results  of  Resection  of  the  Knee-joint. — While 
in  the  case  of  all  other  joints  a  nearthrosis  or  movable  articula- 
tion replacing  the  one  removed  is  aimed  at,  immobility  is  the  ideal 
result  after  resection  of  the  knee-joint,  so  that  a  proper  and 
natural  support  for  the  body  may  be  obtained  (Park).  The 
shortening  present,  which,  in  the  majority  of  cases,  is  not  great, 
is  readily  compensated  for  by  an  extra  thickness  of  the  sole  of 
the  corresponding  shoe;  even  without  this,  in  many  cases,  a 
scarcely  perceptible  limp  is  present  after  a  time,  on  account  of 
the  lateral  tilting  of  the  pelvis.  Experience  shows  that,  even 
in  young  children,  if  only  a  very  thin  slice  of  bone  is  removed, 
particularly  in  the  case  of  the  tibial  epiphysis,  the  restriction  of 


OPERATIONS    UPON    SPECIAL    TISSUES 


337 


growth  is  not  very  great.  Unfortunately,  however,  the  epiphy- 
seal line  of  the  femur  at  least  is  almost  always  encroached  on, 
owing  to  the  extent  of  the  disease.  Eulenburg  reported  several 
cases  of  paralysis  due  to  angulation  of  the  tibial  nerve  in  the 
coaptation  of  the  sawed  surfaces.  Heinke  demonstrated  at 
autopsy  in  one  case  that  the  paralysis  depended  on  the  involve- 
ment of  the  nerve  in  the  surrounding  cicatricial  tissue.  H. 
Braun  was  compelled  to  amputate  in  a  case  in  which  the  sawed 
surface  of  the  tibia  projected  backward  and  made  pressure  on 
the  popliteal  nerve.  In  a  second  case  in  which  the  same  dis- 
placement was  present  this  did  not  occur;  the  displacement 
was  shown  to  exist  by  a  subsequent  amputation  on  account  of 
recurrence  of  the  tuberculous  disease. 

After-treatment  of  Resection  of  the  Ankle-joint. — Copious 
dressings  are  applied,  and  the  foot  supported  by  a  Volkmann's 
posterior  splint  with  foot-piece,  and  two  side  splints. 


Fig.   171. — Bracketed  plaster-of-Paris  splint  for  use  after  resection  of  the 
knee-joint.      (Fowler's  Surgery.) 


Constant  care  and  watchfulness  must  be  used  in  the  after- 
treatment  to  maintain  the  foot  at  a  right  angle  to  prevent 
abduction  or  adduction,  and  to  preserve  the  foot  in  a  position 
midway  between  pronation  and  supination.  Partial  resection 
does  not  give  such  good  final  results  as  complete  resection,  and 
efficient  drainage  is  not  so  easily  secured. 

The  Result  of  Resection  of  the  Ankle-joint. — In  the  absence 
of  damage  to  the  periosteum  from  suppuration,  with  the  excep- 
tion of  tuberculous  cases,  rapid  repair  and  early  usefulness 
of  the  foot  after  subperiosteal  resection  of  the  ankle-joint  is 
the  rule.     The  malleoli  are  reproduced,  often  at  first  exceeding  in 

22 


338 


OPERATING    ROOM    AXD    THE    PATIENT 


size  the  original.  The  shortening  is  slight  in  proportion  to  the 
amount  of  bone  removed,  an  extra  thickness  of  the  sole  of  the 
shoe  supplying  the  deficiency.  A  joint  may  form  in  the  fibrous 
new  formation.  The  mortality,  in  properly  selected  cases,  is 
small.  In  gunshot  injuries  resection,  as  a  rule,  is  to  be  preferred 
to  amputation.  An  unfavorable  prognosis,  however,  is  war- 
ranted in  cases  of  tuberculous  caries  in  individuals  beyond  the 
period  of  growth;  such  cases  usually  reciuii^e  amputation.  If 
performed  early,  resection  in  children  and  young  persons  admits 
of  a  good  prognosis,  as  regards  both  life  and  function. 

Tarsectomy. — The  operation  must  be  followed  by  redress- 
ment  and  pressure  to  maintain  the  reposition.  As  soon  as  the 
wound  has  healed,  the  foot  is  overcorrected  and  a  plaster-of- 
Paris  bandage  applied. 

Ogston's  Operation. — The  foot  is  forced  in  position,  the  thin 
shell  left  behind  readily  adapting  itself  to  the  corrected  shape 
of  the  tarsus,  the  wound  sutured,  and  the  parts  immobilized 
with  plaster  of  Paris. 


Fig.  172. — SajTe  s  apparatus  for  Fig.  173. — SajTe's  shoe  for  clubfoot, 

correction     of     Talipes     Equinus.  (Fowler's  Surgery.) 

(Fowler's  Surgery.) 

Contracture  at  the  Astragalotarsal  Joint.— .\fter  thorough 
and  efficient  correction,  orthopedic  apparatus  is  applied  to 
maintain  the  correction  (Fig.  172). 

Talipes  Equinus   Operation. — Following  successful   correction 


OPERATIONS    UPON    SPECIAL    TISSUES  339 

the  foot  is  first  maintained  in  position  by  a  plaster-of-Paris 
splint;  later  an  apparatus  (Fig.  173)  consisting  of  a  leg  girdle 
connected  to  a  laced  boot  by  two  lateral  splints  and  lever  springs 
attached  to  both  sides  of  the  boot  to  maintain  the  foot  at  a 
right  angle,  should  be  worn.  The  patient  should  be  encouraged 
to  walk  about. 

Lisfranc's  Amputation. — The  loss  of  support  following  Lis- 
franc's  amputation  is  such  that  the  patient  must  wear  a  specially 
constructed  cork  sole  made  thick  on  the  front  and  inner  side,  to 
compensate  for  the  resulting  equinovarus  position. 

The  After-treatment  of  Fractures.^ — In  fractures  of  the  ex- 
tremities the  distal  portion  of  the  extremity  should  be  examined 
frequently  in  order  to  determine  the  condition  of  the  circulation. 
If  pressure  at  the  periphery  produces  a  blanched  appearance 
which  is  slow  in  turning  to  its  normal  color,  and  if  the  parts  are 
slightly  swollen,  the  dressings  should  be  removed  and  reapplied 
in  such  a  manner  as  to  preclude  undue  pressure.  Should  the 
pain  which  is  a  natural  consequence  of  fractures  persist  for  more 
than  a  few  days  following  the  injury,  the  dressings  should  be 
removed  and  reapplied.  This  should  also  be  done  in  case  the 
pain  in  the  first  few  days  is  extremely  severe,  as  ordinarily  the 
pain  following  fractures  is  such  as  to  be  borne  by  the  average 
patient.  Any  complaint  of  burning  pain  over  the  bony  promi- 
nences or  at  the  heel  should  be  inquired  into  without  delay,  other- 
wise an  intractable  pressure  sore  may  develop.  In  an  uncom- 
plicated fracture  there  should  be  practically  no  fever  forty-eight 
hours  following  the  injury.  Should  fever  persist  beyond  this 
period,  the  parts  should  be  inspected,  as  it  may  be  that  the 
fracture  has  become  the  seat  of  a  septic  process.  In  compound 
fractures  frequent  inspection  of  the  parts  and  dressing  of  the 
wound  are  necessary.  Simple  fractures  may  be  allowed  to 
remain  uninspected  for  from  four  to  six  weeks,  unless  the  dress- 
ings become  loose.  In  very  oblique  fractures  the  dressings 
should  be  removed  at  the  end  of  the  second  week  in  order  to 
ascertain  whether  displacement  has  occurred.  Fractures  in  the 
neighborhood  of  joints  in  which  there  is  practically  no  tendency 
to  displacement  should  be  massaged  daily.  The  patient  should 
not  be  confined  to  bed,  in  any  event,  longer  than  is  absolutely 


340  OPERATING  ROOM  AXD  THE  PATIENT 

necessar)^     The    proper    reduction    of    the   fracture    should    be 
verified  by  the  X-ray. 

Late  Complications  of  Fractures. — These  consist  in  edema, 
hematoma,  adhesion  to  muscles  and  tendons,  atrophy  from 
nonuse,  interference  with  the  movements  of  neighboring  joints 
through  excessive  callus  or  inflammatory  exudate,  undue  short- 
ening, and  vicious  callus.  The  first  four  are  benefited  by  mas- 
sage, elastic  bandaging,  passive  movements,  warm  baths,  and 
electricity.  The  interference  with  the  movement  of  neighboring 
bones  and  joints  from  excessive  callus  will  require  operative 
interference.  This  should  not  be  done  until  some  months  have 
elapsed.  Inflammatorj"  exudate  is  treated  by  massage.  Undue 
shortening  reciuires,  in  the  case  of  the  lower  extremity,  a  thicker 
sole  on  the  shoe  worn  on  the  injured  side.  Partial  union  or 
delayed  union  is  treated  by  fitting  a  suitable  brace  to  the  part 
and  allowing  the  patient  to  get  about,  and  the  injection  of  a 
few  minims  of  an  irritating  substance,  perchlorid  of  iron, 
between  the  bone  ends  (Dawbarn). 

The  after-treatment  of  fractures  treated  operatively  differs  only 
by  having  the  care  of  the  wound  added  to  the  usual  fracture 
treatment.  Occasionally  foreign  bodies  introduced  to  maintain 
apposition  will  recjuire  subsequent  removal.  The  general 
health  should  be  improved.  Ununited  fractures  require  opera- 
tion and  subsequent  orthopedic  treatment.  Union  with  deform- 
ity should  be  treated  by  refracture. 

Impacted  Fracture  of  the  Neck  of  the  Femur.  Whitman's 
Method. — The  patient  is  anesthetized.  The  trunk  is  supported 
by  a  box  seven  inches  high  having  an  extension  to  support  the 
pelvis  (Fig.  174).  Assistants  support  the  limbs.  The  unin- 
jured hip  is  abducted  to  the  normal  extent  both  to  demonstrate 
the  amount  of  abduction  and  to  fix  the  pelvis.  Under  exten- 
sion the  injured  hip  is  slowly  abducted  by  an  assistant,  the  sur- 
geon supporting  the  joint  and  exerting  gentle  pressure  down- 
ward upon  the  trochanter.  Traction  and  abduction  are  con- 
tinued until  the  normal  limit  is  reached  when  any  outward 
rotation  is  corrected.  The  parts  are  then  fixed  in  position  by 
a  plaster-of -Paris  cast  including  the  limb  of  the  injured  side,  the 
pelvis,  and  a  sufficient  amount  of  the  trunk  to  produce  a  stable 


OPERATIONS    UPON    SPECIAL    TISSUES  341 

effect.  If  the  fracture  is  complete,  with  the  patient  in  the  same 
position  and  the  sound  limb  held  in  abduction  the  injured  limb 
is  flexed  to  disengage  any  portion  of  the  capsule  which  may  have 
fallen  between  the  fragments,  then  extended  and  rotated  to  the 
normal  position.  With  combined  extension  and  counterexten- 
sion  shortening  is  overcome  as  demonstrated  by  measurement. 
Still  keeping  up  the  extension  the  limb  is  slowly  abducted  by 
an  assistant,  the  surgeon  supporting  the  joint  and  pushing  the 
thigh  upward  from  beneath  to  force  the  two  fragments  against 


Fig.  174. — Whitman's  box  for  application  of  plaster  cast  for  fracture  of  the 

neck  of  the  femur. 

the  anterior  part  of  the  capsule.  In  extreme  abduction  the 
capsule  is  tense,  therefore  the  fragments  must  be  directed 
toward  one  another  by  it  and  the  trochanter  will  be  in  relation 
with  the  side  of  the  pelvis  thus  preventing  upward  displacement, 
and  the  muscles  whose  contraction  favors  deformity  will  be 
completely  relaxed.  A  plaster  cast  is  then  applied.  In  elderly 
patients  the  head  of  the  bed  is  raised  one  or  two  feet;  this  lessens 
the  danger  of  hypostatic  pulmonary  congestion  and  serves  to 
increase  the  blood  supply  at  the  seat  of  injury.  Repair  is  slow 
and  weight  must  not  be  borne  upon  the  limb  for  many  months. 
The  course  of  bone  healing  should  be  observed  by  a  series  of 
X-ray  plates.  After  six  or  eight  weeks  the  cast  may  be  removed 
and  a  modified  hip  splint  substituted.  In  the  course  of  the 
after-treatment  massage  and  passive  and  active  exercises  should 
be  given.  Whitman  considers  by  far  the  most  important  exer- 
cise the  frequent  complete  abduction  of  the  limb. 

Fracture  of  the  Patella.     Open  Operation.- — The  splint   (Fig. 
175)  is  to  be  abandoned  at  the  end  of  ten  days,  and,  as  soon 


342 


OPERATING    ROOM    AND    THE    PATIENT 


thereafter  as  the  skin  wound  is  strongly  healed,  the  patella 
should  be  moved  from  side  to  side  once  or  twice  daily  to  prevent 
the    formation    of    adhesions    (McBurney).     The    patient    may 


Fig.  175. — Dressings  for  fracture  of  the  patella. 


(Fowler's  Surgery.) 


walk  about  in  three  weeks  at  the  most,  the  knee  being  supported 
on  a  posterior  splint  while  he  is  up.  This  should  be  removed 
when  he  lies  down.     Some  passive  movements  ma 5'  be  cautiously 

attempted  from  time  to  time  after 
the  first  three  weeks;  these  may  be 
increased  as  time  passes.  To  prevent 
refract ure  from  an  accidental  fall, 
the  patient  may  wear  a  "check"  ap- 
paratus (Fig.  176). 

Amputations  and  Disarticulations. — 
The  after-trea'bment  of  these  cases 
depends  somewhat  upon  whether  the 
wound  is  left  open  or  is  sutured,  upon 
the  lesion  necessitating  the  operation, 
and  upon  the  technic  employed. 

General  Rules.     Stay  in  Bed. — It  is 

desirable  to  get  these  patients  out  of 

bed  and  in  the  sunlight  as  quickly  as 

their   general    condition   will    permit. 

Usually  four  or  five  days'  rest  in  bed 

will  be  sufficient.     The  patient  may 

then   be   lifted  into  a  wheel  chair  if 

this  wUl  not  interfere  with  the  rest  of 

the  wound  which  must  be  kept  quiet  for  ten  days.     Crutches  after 

amputation  upon  the  lower  extremity  may  be  used  on  the  tenth 

day  or  as  soon  thereafter  as  wound  healing  is  practically  complete. 


Fig.  176. — Brace  for  frac- 
ture of  the  patella.  (Fowl 
er's  Surgery.) 


OPERATIONS    UPON    SPECIAL    TISSUES  343 

Care  of  the  Wound. — The  regular  stump  dressing  is  applied 
(p.  345)  in  all  cases.  The  outer  dressing  is  changed  at  the  end 
of  forty-eight  hours  or  sooner  if  soiled.  Sutures  are  removed 
on  the  tenth  day.  The  tender  cicatrix  is  then  supported  by 
narrow  strips  of  adhesive  plaster.  Drainage  in  cases  treated 
openly  has  been  sufficiently  discussed.  In  cases  sutured  pri- 
marily it  iS;  as  a  rule,  unnecessary  to  employ  drainage,  the 
spaces  between  the  sutures  being  usually  sufficient  to  allow  of 
the  escape  of  serum.  Should  oozing  be  expected,  due  to  the 
great  vascularity  of  the  parts,  it  is  well  to  provide  for  its  escape 
by  placing  a  small  drainage  tube  in  each  angle  of  the  wound.  In 
such  cases  a  provisional  suture  is  placed  at  the  point  of  emer- 
gence of  each  drain  to  be  tightened  upon  removal  of  the  drains. 
These  are  removed  on  the  second  day  and  the  wound  redressed 
without  drainage. 

Shock  depends  upon  the  condition  of  the  patient  and  the  site 
of  the  amputation.  It  is  minimized  by  cocainizing  the  principal 
nerve  trunks  of  the  extremity  (Crile).  When  present  it  is 
combated  by  the  usual  measures. 

Infection. — As  the  areas  involved  in  the  operation  are  large, 
yet  in  intimate  relation  infection  once  initiated  rapidly  attacks 
all  parts  of  the  wound  and  the  danger  of  general  infection  is 
imminent.  Immediately  upon  the  occurrence  of  infection  the 
site  of  infection  must  be  widely  opened,  if  necessary  removing 
all  the  sutures.  Absolutely  free  drainage  must  be  provided. 
A  copious  alcohol-bichlorid  dressing  is  applied  to  the  infected 
surfaces.  These  are  renewed  several  times  daily  until  the  sub- 
sidence of  the  infection.  When  the  wound  is  clean  secondary 
suturing  is  done. 

Necrosis  of  the  Flaps. — This  may  arise  from  trauma,  sepsis, 
or  arteriosclerosis,  or  a  combination  of  these  causes.  The 
trauma  may  be  the  result  of  the  original  injury  or  may  result 
from  an  injudicious  primary  suturing.  Dead  portions  of  the 
flap  are  removed  at  each  dressing  and  both  local  and  general 
stimulating  treatment  inaugurated  to  bring  the  parts  to  a  healthy 
condition.  The  separation  of  dead  from  healthy  tissue  is  thus 
hastened.  Should  the  sutures  be  .at  fault,  these  are  removed 
and  perfectly  free  drainage  established.     Necrosis  may  involve 


344  OPERATIXG    ROOM    AXD    THE    PATIEXT 

the  bone  itself,  in  -^-hich  case  the  bone  is  curetted,  Shoulcl' necro- 
sis prove  extensive,  a  second  amputation  will  be  necessitated, 
and  in  performing  this  it  is  well  to  bear  in  mind  and  guard  against 
those  conditions  which  produced  necrosis  in  the  first  instance. 

Bone  Necrosis. — Every  operation  upon  bone  involves  trau- 
matism which  may  result  in  bone  necrosis.  This  necrosis  may 
be  only  superficial  and  result  in  a  small  fistula  which  readily 
heals  following  curetting  or  more  extensive  necrosis  with  for- 
mation of  sec{uestra  and  persistent  sinus  may  result.  In  the 
latter  event  it  will  be  necessary  to  enlarge  the  sinus  sufficiently 
to  remove  the  sequestra  and  in  some  cases  to  even  remove  a 
considerable  portion  of  the  end  of  the  bone. 

The  cicatrix  in  cases  sutured  primarily  or  secondarily  will  be 
linear;  in  other  cases  it  will  depend  upon  the  care  of  the  open 
wound.  If  healing  occurs  by  granulation  alone  there  will  result 
a  broad  cicatrix,  but  if  the  healing  process  is  aided  by  support 
of  the  structures  and  the  partial  approximation  and  partial 
closure  of  the  wound  b}^  adhesive  plaster  and  skilKul  bandaging, 
then  a  fairly  good  cicatrix  will  result.  It  is  desirable  that  as 
little  scar  tissue  as  possible  be  in  the  stump,  as  this  scar  tissue 
is  frequently  the  cause  of  pain,  either  through  inclosure  of  nerve 
filaments  or  by  external  pressure. 

Painful  conditions  of  the  stump  may  ensue.  These  may  be 
due  to  inclusion  of  nerve  filaments  in  the  callus,  to  neuromata 
developing  at  the  severed  ends  of  large  nerves,  to  bony  necrosis 
and  resulting  fistulse,  and  to  inefficient  protection  of  the  severed 
end  of  the  bone.  If  these  conditions  prove  persistently  painful 
it  will  be  necessary  to  perform  a  secondary  operation  for  their 
cure.  They  may  in  great  measure  be  prevented  by  skillful 
technic  in  the  operation  and  in  the  after-care.  To  guard 
against  them  the  formation  of  scar  tissue  must  be  reduced  to  the 
minimum,  large  nerves  must  be  cut  squarely  across  and  at  as 
high  a  level  as  possible.  This  is  accomplished  by  traction  on 
the  nerve  in  the  wound.  Careful  asepsis  and  avoidance  of 
unnecessary  traumatism  to  the  bone  wiU  guard  against  bony 
necrosis.  The  end  of  the  bone  itself  maj^  be  covered  by  a  bone 
graft  (Bier)  or  the  medullary  cavity  of  the  larger  bones  may  be 
plugged  with  an  appropriately  shaped  piece  of  bone  taken  from 


OPERATIONS    UPON    SPECIAL    TISSUES  345 

the  amputated  portion.  This  is  driven  tightly  into  the  medul- 
lary canal  for  an  inch,  and  one-quarter  of  an  inch  left  projecting 
beyond  the  sawed  end  of  the  bone. 

Bandaging  of  the  stump  should  be  done  daily  until  an. artifi- 
cial limb  is  applied.  The  patient  should  be  instructed  how  to 
properly  apply  the  bandage.  Flannel  makes  the  most  desirable 
bandage  and  the  one  most  easily  applied  by  the  patient.  The 
bandage  should  be  removed  at  night  and  the  stump  massaged, 
at  first  gently,  later  more  vigorously. 

Cases  in  which  Primary  Suturing  is  Done. — This  should  be 
employed  in  all  cases  which  admit  of  it  as  it  undoubtedly  not 
only  induces  more  rapid  healing,  but  produces  a  more  perfect 
stump.  The  severed  ends  of  opposing  muscles  should  be 
sutured  together  in  order  to  limit,  to  some  extent  at  least,  the 
amount  of  atrophy.  The  skin  sutures  should  be  sufficiently 
distant  from  each  other  to  permit  the  escape  of  serum  from  the 
depths  of  the  wound,  and  should  interfere  in  no  way  with  the 
blood  supply  of  the  flap.  There  should  be  no  tension.  In  cases 
sutured  primarily  there  should  be  no  indications  for  disturbing 
the  stump  dressing  proper  before  the  tenth  day.  At  this  time 
the  skin  sutures  are  removed.  It  may  have  been  necessary  to 
change  the  outer  dressing  on  the  first  or  second  day  on  account 
of  oozing. 

In  traumatic  cases  it  frequently  happens  that  the  condition 
of  the  patient  does  not  allow  of  more  than  the  control  of  hem- 
orrhage, the  rapid  removal  of  the  limb,  and  the  trimming  of  the 
flaps.  To  do  more — i.  e.,  to  accurately  suture  the  flaps — would 
be  more  than  the  weakened  condition  of  the  patient  would  per- 
mit. Moreover,  the  contused  condition  of  the  soft  parts  is 
such  that  to  suture  them  accurately  would  be  to  invite  sepsis. 
The  flaps  in  such  a  case  are  left  unsatured  or  only  partially 
sutured  and  the  wound  cavity  filled  with  dry  sterile  gauze.  The 
stump  is  then  enveloped  in  gauze  and  this  stump  dressing  secured 
by  a  gauze  bandage.  Over  this  again  are  placed  other  layers 
of  gauze,  and  this  in  turn  is  secured  by  a  bandage  which  in- 
cludes the  neighboring  parts  sufficiently  to  prevent  slipping; 
in  the  case  of  the  thigh,  the  pelvis  should  be  included;  in  the 
case  of  the  leg,  the  knee  and  thigh.     The  dressing  is  applied  in 


346  OPERATING    ROOM    AND    THE    PATIEXT 

this  manner  because  in  such  cases  there  is  expected  a  large 
amount  of  oozing.  This  quickly  saturates  the  dressing  and 
predisposes  to  sepsis.  By  having  an  outer  as  well  as  an  inner 
dressing  the  outer  one  can  be  changed,  as  soon  as  the  oozing  is 
apparent,  without  disturbing  the  stump  dressing  proper.  This 
not  only  conduces  to  the  comfort  of  the  patient,  but  guards 
against  infection  of  the  wound  by  too  frequent  change  of  dressing. 
In  cases  in  which  there  is  a  joint  between  the  site  of  amputation 
and  the  trunk,  as  in  case  of  the  forearm  or  leg,  it  is  well  to  apply 
a  well-padded  splint  to  control  the  movements  of  the  extremity 
and  to  prevent  contractm-es.  The  splint  should  extend  a  few 
inches  beyond  the  stump  to  protect  it  from  injury.  The  parts 
should  be  supported  and  elevated  by  soft  pillows. 

Shock  should  be  treated  on  the  lines  already  laid  down,  but 
infusion  should  not  be  employed  until  the  source  of  the  hem- 
orrhage has  been  secured.  The  stump  dressing  proper  need 
not  be  disturbed  for  three  or  four  days,  except  in  case  of  hem- 
orrhage or  infection.  At  this  dressing,  if  the  parts  are  unin- 
fected and  the  patient's  condition  warrants  it,  secondarj^  sutur- 
ing should  be  done  under  local  anesthesia.  Otherwise  the 
wound  is  treated  openly  until  a  more  opportune  time  arrives 
for  further  interference.  In  those  cases  which  cannot  be  sutured 
secondarily  the  use  of  adhesive-plaster  straps  will  greatly  aid  in 
reducing  the  size  of  the  wound  and  producing  a  well-formed 
stump.  There  are  a  few  of  these  cases  whose  condition  is  so 
serious  that  no  immediate  operative  intervention  can  he  employed. 
In  such  cases  the  tourniquet  is  left  in  place  for  from  twelve  to 
twenty  hours  until  stimulation  has  decreased  the  primary  shock. 
Such  cases  maj'  be  infused  intravenously,  or,  better,  intracellu- 
larl}'.  They  must  be  closely  watched  to  prevent  slipping  of  the 
tourniquet  and  a  recurrence  of  the  hemorrhage.  Overstimula- 
tion must  be  guarded  against.  Of  course  this  is  only  done  in 
very  serious  cases,  as  the  pressure  of  the  tourniquet,  while  it 
may  not  severely  injure  the  skin,  does  produce,  if  left  on  for 
more  than  a  few  hours,  a  vasomotor  paralysis  of  the  vessels, 
which  results  in  a  ver}'  persistent  oozing  upon  the  final  removal 
of  the  tourniquet  (p.  260). 

There  remain  two  other  classes  of  cases  in  which  no  primary 


OPERATIONS    UPON    SPECIAL    TISSUES  347 

suturing  is  clone — those  in  which  infection  is  indubitably  present 
or  very  apt  to  occur,  and  those  in  which  the  reparative  process 
of  the  tissues  is  weakened.  As  notable  examples  of  the  first  we 
have  osteomyelitis,  moist  gangrene,  and  extensive  septic  conditions; 
of  the  second,  arteriosclerotic  conditions,  such  as  senile  gangrene. 
To  secure  the  flaps  by  suturing  in  the  first  class  would  be  to 
invite  an  inevitable  sepsis;  in  the  second  class  would  still  further 
impair  the  integrity  of  the  flap  by  interfering  to  too  great  an 
extent  with  its  already  poor  blood  supply.  The  first  class  are, 
therefore,  treated  as  open  wounds  until  proved  clean.  Such 
wounds  should  be  dressed  at  the  end  of  forty-eight  hours  and 
daily  thereafter.  As  soon  as  the  septic  condition  is  under  con- 
trol adhesive-plaster  straps  are  employed  to  aid  in  reducing  the 
area  of  the  wound.  Secondary  suturing  is  done  in  whole  or  in 
part  as  soon  as  the  wound  presents  a  healthy  appearance. 

In  senile  gangrene  and  allied  conditions  one  or  two  sutures 
may  approximate  the  flaps,  but  for  the  most  part  no  interference 
with  their  blood  supply  is  allowable.  The  dressing  in  such  cases 
must  not  exert  the  least  pressure.  As  soon  as  time  has  demon- 
strated the  integrity  of  the  flaps  secondary  suturing  is  done. 
This  can  usually  be  determined  in  seven  or  eight  days.  Such 
cases  are  so  treacherous  and  so  apt  to  result  in  necrosis  of  the 
flaps  that  high  amputation  is  advisable  in  most  cases,  but  for 
this  no  general  rule  can  be  laid  down.  The  condition  of  the 
artery  wall  will  aid  to  some  extent.  If  one  is  quite  sure  of  the 
viability  of  the  flaps  primary  suturing  may  be  done.  Cases  of 
arteriosclerosis  are  best  left  in  their  primary  dressing  for  three  or 
four  days.     Later  these  are  dressed  every  second  or  third  day. 

Operations  through  or  near  the  shoidder  girdle  are  more  apt 
to  be  complicated  by  pneumonia.  FoUowing  these  operations 
the  patient  is  propped  up  in  bed  as  soon  as  out  of  the  anesthetic. 
In  amputation  upon  the  upper  extremity  below  the  shoidder  proper 
rest  to  the  parts  is  secured  by  bandaging  to  the  chest.  If  the 
amputation  is  below  the  elbow,  the  joint  should  be  kept  extended 
by  a  posterior  splint.  FoUowing  operation  through  or  near  the 
hip-joint  care  is  necessary  to  avoid  soiling  of  the  dressing  by 
fecal  matter;  the  bowels  may  be  kept  quiet  for  three  or  four 
days.     The   dressing   is   inspected  frequently   and   changed   as 


348 


OPERATING    ROOM    AND    THE    PATIENT 


often  as  soiled.  There  is  usually  considerable  serous  discharge 
•which  will  necessitate  more  frequent  change  of  outer  dressing 
than  is  the  case  in  other  amputations.  Following  avifutations 
through  the  thigh  a  splint  should  be  applied  to  overcome  the  action 
of  the  flexors  and  abductors,  otherwise  through  their  contraction 
a  stump  useless  for  prosthetic  purposes  will  result.  The  same  is 
true  following  amputation  below  the  knee;  a  posterior  splint 
should  be  applied.  Following  amputation  of  the  toes  or  forefoot, 
weight  must  not  be  put  on  the  foot  before  two  weeks  or  until 
union  is  firm.  A  plantar  splint  is  kept  applied  and  the  ankle 
bandaged  to  limit  motion  for  the  same  length  of  time. 

Prosthesis. — The  question  of  a  prosthetic  apparatus  is  too 
often  left  to  the  patient  and  instrument-maker.  It  will  repay 
the  surgeon  to  make  a  study  not  only  of  pros- 
thetic apparatus  as  applied  to  stumps,  but  also 
those  used  to  overcome  defects  in  other  parts 
of  the  body.  An  artificial  limb  should  not  be 
applied  until  cicatrization  is  complete  and  the 
stump  has  assumed  the  proportions  which  may 
be  expected  to  be  permanent.  From  six  weeks 
to  three  months  may  elapse.  During  this  time 
the  patient  goes  about  on  crutches.  Massage 
and  passive  and  active  movement  of  the  stump 
should  be  employed  to  minimize  the  amount  of 
atrophy.  As  soon  as  the  process  of  atrophy 
has  become  stationary,  as  determined  by  occa- 
sional measurements,  the  artificial  limb  should 
be  applied.  After  some  months  further  atrophy 
of  the  stump  may  occur,  necessitating  change 
in  the  prosthetic  apparatus. 
Hallux  Valgus. — The  toe  is  maintained  for  two  weeks  in  the 
corrected  position  in  slight  flexion  by  a  side  splint  or  by  packing 
gauze  between  it  and  the  adjacent  toe  and  securing  it  in  position 
(Fig.  177).  To  prevent  recurrence  a  divided  stocking  and  a 
leather  insole  (Fig.  178)  with  a  vertical  partition  should  be 
worn.  If  slight  flexion  has  not  been  maintained  and  ankylosis 
follows,  a  pressure  sore  is  apt  to  develop  on  the  under  surface  of 
the  toe. 


Fig.  177.— 
Dressing  after 
operation  for 
hallux  valgus. 
(Fowler's  Sur- 
gery.) 


OPERATIONS    UPON    SPECIAL    TISSUES  34,9 

Ostetomy  of  the  Tibia  for  Bow-legs.— After  the  limb  has  been 
straightened  a  plaster-of-Paris  casing  is  applied  extending  from 
the  base  of  the  toes  to  the  gluteal  fold.  After  ten  days  this  is 
bivalved  laterally,  the  sutures  are  removed  and  if  any  additional 
correction  is  necessary  this  may  be  done  and  a  second  plaster 
cast  applied.  The  treatment  from  now  on  is  that  of  simple  frac- 
ture. It  is  particularly  necessary  if  the  curve  has  been  low  down 
on  the  tibia  that  the  foot  be  prevented  from  falling  backward. 
In  any  event  the  foot  must  be  kept  at  a  right  angle  with  the  leg, 


Fig.   178. — Inside  sole  for  use  in  hallux  valgus.      (Fowler's  Surgery.) 

otherwise,  shortening  of  the  tendon  achilles  will  result.  Atrophy 
is  prevented  by  daily  massage,  the  splint  being  bivalved  for  this 
purpose.  Massage  also  hastens  firm  union.  The  treatment  of 
any  underlying  constitutional  disturbance  is  essential.  At  the 
end  of  four  weeks  there  will  usually  be  sufficient  union  to  pre- 
vent recurrence  of  the  deformity.  At  the  end  of  the  sixth  week 
the  plaster  cast  may  be  replaced  by  a  molded  plaster  splint  and 
the  child  allowed  up  and  about.  A  light  splint  should  be  worn 
for  six  months  at  the  end  of  which  time  all  apparatus  may  be 
removed. 

Osteotomy  for  Genu  Valgum. — After  the  limb  has  been  straight- 
ened a  plaster-of-Paris  cast  is  applied  which  should  include  the 
pelvis  and  ankle.  At  the  end  of  ten  days  this  cast  is  bivalved 
laterally  and  the  sutures  removed.  Daily  thereafter  the  anterior 
portion  of  the  cast  is  removed  and  the  muscles  massaged  to  pre- 
vent atrophy.  At  the  end  of  the  second  week  or  as  soon  there- 
after as  slight  union  is  present  passive  movements  of  the  knee- 
joint  may  be  added  to  the  muscular  massage.  At  the  end  of  the 
fourth  week  the  cast  may  be  removed  and  if  the  union  is  moder- 
ately firm  as  is  usually  the  case,  the  patient  is  allowed  to  move 
about  in  bed,  but  walking,  sitting  or  standing  should  not  be 
allowed  until  the  end  of  the  sixth  week,  and  only  then  when 
union   is   good.     Subsequently,    particularly   in   young    adults, 


350 


OPERATING    ROOM    AXD    THE    PATIENT 


if  there  is  any  doubt  as  to  union  being  firm  it  is  best  that  the 
patient  wear  some  form  of  a^Dparatus  to  prevent  recurrence  of 


Fig.   179. — Genu    valgum,    showing    Tiemann's    brace    applied.      (Toiler's 

Surgery.) 


the  deformity  (Fig.  179).  It  may  be  necessary  to  •^■ear  an  appa- 
ratus of  this  kind  for  six  months.  Here,  as  in  all  such  conditions, 
anv  underlving  constitutional  cause  must  be  treated. 


OPERATIONS  UPON  THE  HEAD  351 


CHAPTER  XIII. 
OPERATIONS  UPON  THE  HEAD. 

The  Scalp. — Wounds  of  tlie  scalp  heal  readily  and  are  rarely 
subject  to  infection  by  reason  of  the  excellent  blood  supply  of 
the  parts  and  the  accuracy  with  which  such  wounds  can  be 
sutured.  The  evenness  of  the  underlying  hard  parts  prevents 
the  formation  of  pockets.  Careful  asepsis  must  be  observed, 
for  if  infection  occurs,  it  may  readily  be  carried  to  the  meninges 
through  the  extensive  direct  communications  between  the  ves- 
sels of  the  soft  parts  and  those  of  the  diploe,  and  through  these 
with  those  of  the  cerebral  membranes.  Abscess  of  the  brain, 
meningitis  or  osteomyelitis  of  the  cranial  bones  may  complicate 
even  apparently  insignificant  infected  scalp  wounds.  Throm- 
bosis, embolism  and  pyemia  may  be  caused  by  infection  carried 
through  the  parietal  emissary  vein  into  the  superior  longitudinal 
sinus;  through  the  occipital  and  posterior  auricular  veins  and 
their  communications  with  the  mastoid  vein  into  the  lateral 
sinus;  through  the  diploic  veins  and  the  pericranial  veins  into 
the  sinus  alse  parvse;  through  the  fronto-sphenoid  diploic  vein 
into  the  cavernous  sinus;  through  the  anterior  temporal  dip- 
loic vein  into  the  superior  petrosal  sinus;  through  the  posterior 
temporal  and  occipital  diploic  veins  into  the  lateral  sinus. 
Clean  wounds  are  treated  along  the  lines  already  laid  down. 
Infection  is  usually  the  result  of  carelessness  on  the  part  of  the 
patient.  Should  infection  occur  free  drainage  with  prompt  and 
careful  mechanical  cleansing  of  the  wound  should  be  immediately 
instituted. 

In  plastic  operations,  such  as  covering  in  defects,  it  will  be 
found  that  even  large  flaps  heal  readily,  though  they  may  be 
placed  on  bare  bone.  This  is  probably  due  to  the  accurate 
apposition  and  immobilization  of  the  parts  which  is  possible 
in  this  neighborhood,  as  well  as  the  generous  blood  supply.  In 
covering  in  such  defects  the  hairy  parts  of  the  scalp  should  be 
utilized  as  much  as  possible  to  avoid  the  occurrence  of  bald 


352  OPERATING    ROOM    AND    THE    PATIENT 

spots.  If  this  is  impossible  the  bald  spots  should  be  so  placed 
as  to  allow  of  their  being  concealed  by  hair  from  other  parts  of 
the  scalp.  If  this  also  is  impossible  a  wig  may  be  worn.  Inge- 
nuity will  do  much  toward  avoiding  such  deformity.  Following 
operations  for  tuberculous  bone  disease,  repeated  curettements 
and  daily  dressing  with  Peruvian  balsam  will  usually  effect  a 
cure.  Skin-grafting  may  later  be  necessary.  The  same  applies 
to  syphilitic  necrosis  with  the  addition  of  iodid  of  potassium 
and  mercury.  In  such  cases  the  hypodermic  use  of  the  salic- 
ylate of  mercury  is  beneficial.  In  bone  necrosis  complicating 
injuries  to  the  scalp,  superficial  thin  plates  of  bone  exfoliate  as 
granulation  progresses  beneath  them.  Areas  the  size  of  a  silver 
dollar  may  exfoliate  in  this  way.  These  plates  should  be  re- 
moved  with  forceps.   Beneath  them  are  seen  healthy  granulations. 

Erysipelas  is  an  uncommon  but  dreaded  complication  of 
wounds  of  the  scalp.  The  redness  which  accompanies  ery- 
sipelas elsewhere  is  not  shown  in  erysipelas  of  the  scalp.  Instead 
there  is  a  pale  edematous  swelling  which  spreads  to  the  lower 
margins  of  the  scalp.  When  the  margins  of  the  scalp  are  reached 
redness  occurs,  as  the  mechanical  conditions  which  prevented 
its  occurrence  above  do  not  here  obtain^  The  absence  of  redness 
is  due  to  the  fact  that  the  tension  of  the  tissues  of  the  scalp 
pressing  upon  the  bony  wall  beneath  prevents  the  overfilling 
of  the  capillaries.  An  edematous  puffy  condition  of  the  scalp, 
accompanied  by  a  chill  and  an  elevation  of  temperature,  should 
always  be  looked  upon  with  suspicion  as  the  probable  initial 
stage.  Cerebral  symptoms — headache,  restlessness,  delirium 
and  sleeplessness — are  more  marked  than  in  erysipelas  else- 
where. There  is  great  danger  of  meningeal  infection,  septic 
arachnoiditis  or  leptomeningitis  should  the  infection  be  a 
mixed  one,  i.e.,  complicated  by  streptococcus  or  staphylococcus 
(see  Erysipelas  p.  276).  The  cortex  of  the  brain  may  finally 
take  part  in  the  process.  Should  a  phlegmonous  process  com- 
plicate the  erysipelatous  inflammation,  multiple  incisions  should 
be  made  and  copious  evaporating  dressings  applied. 

Phlegmonous  inflammation  of  the  scalp  is  fortunately  rare. 
The  infection  travels  rapidly  and  the  entire  scalp  may  be  raised 
from  the  cranial  bones  from  the  sinciput  to  the  occiput.     The 


OPERATIONS  UPON  THE  HEAD  353 

scalp  pits  upon  pressure  and  there  is  acute  tenderness,  accom- 
panied by  severe  pain  and  high  fever.  Fluctuation  is  not  usu- 
ally present.  It  is  best  to  shave  the  entire  scalp  and  make  a 
number  of  parallel  incisions  two  to  three  inches  in  length. 
These  incisions  should  run  from  before  backward,  and  should  be 
in  portions  of  the  scalp  which  will  subsequently  be  covered  with 
hair.  The  flaps  so  made  should  be  raised  up  and  the  large 
cavity  curetted  and  thoroughly  cleansed.  Strips  of  gauze  should 
be  placed  under  the  flaps  and  the  flaps  should  be  kept  from 
growing  fast  to  the  underlying  bone  until  the  phlegmonous  proc- 
ess has  subsided.  If  this  is  not  done  great  difficulty  will  be 
experienced  later  in  performing  secondary  suture  of  the  incisions 
as  the  flaps  become  readily  adherent  to  the  underlying  bone. 
During  the  height  of  the  inflammation  copious  evaporating 
dressings  should  be  used.  These  should  be  changed  frequently 
as  they  become  soiled  and  the  wound  irrigated  twice  daily. 

Differential  diagnosis  between  erysipelas  and  'phlegmonous 
inflammation  in  the  early  stages  is  not  possible.  They  are 
frequently  found  in  combination.  The  peculiar  redness  of  the 
skin  in  erysipelas  when  the  bony  boundaries  have  been  passed 
is  a  diagnostic  point  of  value.  The  rapidity  with  which 
phelgmonous  inflammation  suppurates  is  also  of  use  in  the 
differentiation. 

Compound  Fractures  Without  Depression. — The  initial  treat- 
ment consists  in  trimming  the  wound  edges  and  thorough  dis- 
infection of  the  wound.  To  provide  adequate  drainage  for  the 
lines  of  fracture  these  should  be  exposed  and  the  edge  of  the 
fracture  beveled  with  a  chisel  and  mallet,  or  burred  with  a  sur- 
gical engine,  to  drain  the  diploe.  This  is  made  necessary  by 
the  fact  that  when  these  fissures  are  formed  they  gap  widely 
though  momentarily,  and  foreign  bodies  and  hairs  enter  and 
become  imprisoned  as  the  fissure  closes.  Drainage  is  obtained 
by  means  of  several  strips  of  green-silk  protective  led  out  of  the 
wound  in  pairs  so  that  capillary  drainage  is  affected.  For  the 
most  part  the  wound  may  be  closed.  In  the  absence  of  con- 
traindications the  drains  may  be  removed  in  from  twenty-four 
to  forty-eight  hours  and  the  wound  allowed  to  heal.  Rarely 
does  infection  occur  in  such  wounds. 

23 


354  OPERATING    ROOM    AND    THE    PATIENT 

After-treatment  of  Trephining. — The  compHcations  in  the 
after-course  of  trephining  operations  depend  to  a  large  extent 
upon  the  lesion  for  which  the  operation  is  done.  In  cases  of 
compound  fractures  with  depression  if  the  dura  has  not  been  torn 
the  wound  usually  pursues  a  normal  course  following  the  eleva- 
tion of  the  depressed  portions  and  removal  of  the  comminuted 
pieces  of  bone.  The  same  rules  apply  as  in  compound  fracture 
without  depression.  Fissures  should  be  followed  up  and  burred 
or  beveled;  drainage  should  be  more  free  and  should  not  be 
removed  so  soon  as  serous  discharge  is  more  profuse.  In  addi- 
tion a  careful  watch  of  the  general  condition  must  be  main- 
tained, especially  in  cases  which  were  accompanied  with  symp- 
toms of  concussion  or  compression.  It  cannot  be  too  forcibly 
impressed  upon  the  attendant  that  all  symptoms  are  to  be 
noted,  the  pulse,  respiration,  temperature,  blood  pressure, 
mental  condition,  headache,  twitching,  paralysis,  restlessness, 
sleeplessness,  condition  of  the  nerves  of  special  sense,  disturb- 
ance of  speech,  reaction  of  the  pupil,  the  ophthalmoscopic  find- 
ings, and  disturbance  of  the  bladder  and  rectum.  Half-hourly 
observations  of  the  pulse  and  respiration  are  of  special  impor- 
tance in  all  cases  of  head  injury.  All  these  symptoms  have  a 
very  important  bearing  on  the  course,  treatment  and  prognosis 
of  the  case.  In  cases  in  which  the  dura  was  opened  the  addi- 
tional complication  of  hernia  cerebri  and  escape  of  cerebrospinal 
fluid  must  be  considered. 

In  operations  for  cerebral  compression  certain  symptoms 
may  improve  during  the  course  of  the  operation,  the  breathing 
may  become  less  stertorous,  the  pulse  more  rapid,  and  a  certain 
degree  of  consciousness  may  develop  and  the  previously  paralyzed 
extremities  may  move.  Complete  consciousness  does  not  return 
as  a  rule  for  several  hours  (2-24).  The  choked  disc  disappears. 
Sleepiness,  lassitude,  and  dull  headache  usually  persist  for 
several  days.  Complete  return  of  motion  to  the  paralyzed 
parts  is  slow.  In  cases  of  actual  destruction  of  brain  tissue, 
laceration,  the  paralysis  persists  and  recovery  of  motion,  if  it 
occurs  at  all,  is  imperfect,  though  in  time  and  with  careful  treat- 
ment much  may  be  done  even  for  these  cases.  In  paralysis 
of  long  standing,  contractures  must  be  guarded  against. 


OPERATIONS  UPON  THE  HEAD  355 

In  cases  of  tomipression  from  middle  meningeal  hemorrhage 
after  the  operation  and  after  the  symptoms  have  cleared  up, 
secondary  unconsciousness  may  occur  and  the  symptoms  of 
compression  again  develop.  This  is  more  apt  to  happen  in 
cases  in  which  the  original  operation  consisted  simply  in  clearing 
out  the  clot  and  affording  drainage  without  ligation  of  the 
middle  meningeal.  The  hemorrhage  recurs,  the  drain  becomes 
clogged,  and  the  brain  is  again  compressed.  Removal  of  the 
dressing  and  examination  of  the  wound  reveals  the  true  trouble. 
The  treatment  is  to  open  the  wound  in  its  entirety  and  repeat 
the  original  operation  with  the  addition  of  ligating  the  bleeding 
vessel.  Hemorrhage  from  the  vessels  of  the  brain  itself  is 
usually  insignificant  and  promptly  subsides  if  free  drainage  is 
provided.  In  any  event  pressure  must  be  avoided.  Slow 
pulse  occurring  on  the  day  following  the  operation  is  not  of  itself 
sufficient  to  warrant  renewed  intracranial  exploration  for  it  not 
infrequently  happens  in  cases  of  concussion  that  while  the  pulse 
is  accelerated  for  the  first  day,  a  subnormal  pulse  occurs  on  the 
day  following  the  injury.  This  may  be  due  to  ecchymosis  in  the 
neighborhood  of  the  vagus  center. 

In  the  case  of  an  abscess  which  has  been  drained,  or  brain 
tumor  which  has  been  removed  and  drainage  inserted,  drainage 
must  be  maintained  sufficiently  long  to  ensure  complete  empty- 
ing. Should  symptoms  of  compression  develop  it  is  probable 
that  the  drain  has  become  clogged  and  retention  of  secretion 
has  occurred.  This  necessitates  prompt  removal  of  the  drain, 
gentle  irrigation  of  the  cavity,  and  the  reestablishment  of  drain- 
age by  means  of  strips  of  green-silk  protective.  The  symptoms 
of  compression  may  occur  later,  after  the  removal  of  the  drain, 
and  when  the  case  is  apparently  pursuing  a  normal  course.  If 
so,  the  wound  must  be  opened  and  drainage  instituted,  as  the 
cause  of  such  pressure  symptoms  is  an  accumulation  of  fluid  in 
the  old  abscess  cavity  or  in  the  cavity  left  by  removal  of  the 
tumor.  It  is  better  to  remove  such  drains  slowly  (three  to  five 
days),  in  order  to  avoid  this  complication.  Hemorrhage  may 
occur  into  the  cavity  left  from  removal  of  a  growth.  If  it  occurs 
before  the  drain  has  been  removed,  no  symptoms  other  than  the 
increased   discharge    of    blood   will    be   noted.     Following   the 


356  OPERATIXG    ROOM    AND    THE    PATIENT 

removal  of  the  drain,  however,  symptoms  of  compression  will 
develop.  Treatment  is  to  open  the  wound  and  reestablish 
drainage.  Edema  of  the  Brain  and  Cerebral  Softening. — These 
are  the  result  of  injury  to  the  brain  substance.  The  symptoms 
appear  a  few  days  following  the  operation  and  usually  disappear 
quicklv.  This  is  usually  limited  to  the  immediate  neighborhood 
of  the  operation  and  is  temporary.  In  some  cases,  however, 
the  process  is  more  extensive  and  amounts  to  an  encephalitis. 
The  occurrence  of  the  lesion  is  shown  by  symptoms  traceable 
to  derangement  of  brain  function  occurring  after  the  lapse  of 
some  days. 

Treatment. — If  the  drain  has  been  removed  it  should  be  rein- 
serted. If  the  drain  is  still  in  place  a  careful  investigation 
should  be  made  to  see  if  it  is  not  obstructed.  This  will  be 
followed  b}'  a  discharge  of  fluid  or  even  of  brain  substance  follow- 
ing which  the  symptoms  will  usually  subside. 

Congestion  of  the  brain  may  develop  after  any  operation 
involving  the  dura,  but  it  is  more  likely  to  develop  in  cases  of 
injury  to  the  brain  itself.  Its  presence  is  shown  by  general 
headache,  restlessness,  sleeplessness,  and  finally  wild  delirium. 
The  face  becomes  congested,  and  the  pulse  rapid  and  full.  Should 
the  temperature  remain  normal  the  case  is  one  of  congestion  of 
the  brain,  but  should  fever  accompany  these  symptoms,  then 
the  case  has  developed  a  meningitis.  There  is  an  exception  to 
this  rule,  i.e.,  cases  in  which  the  original  injury  has  involved- 
the  heat-controlling  center.  This  is  rare,  however.  The  most 
frequent  cause  is  infection.  Change  of  dressing  wiU  show  pus 
coming  from  the  interior  of  the  skull,  through  the  injury  or  site 
of  operation.     The  prognosis  is  bad. 

Meningitis. — The  first  symptom  is  usually  a  rise  of  tempera- 
ture and  some  acceleration  of  the  pulse.  The  pulse  is  not  rapid 
in  proportion  to  the  height  of  the  fever  on  account  of  the  intra- 
cranial pressure.  The  onset  of  symptoms  is  rapid.  A  chill 
may  precede  the  rise  in  temperature.  The  patient  becomes 
gradually  unconscious  and  comatose,  the  breathing  stertorous. 
If  the  motor  area  is  affected,  paralysis  develops.  If  the  base  is 
affected,  there  develops  paralysis  of  the  nerves  of  special  sense, 
iit  first  there  is  uTitation  and  later  paralysis  of  the  vagus  and 


OPERATIONS    UPON    THE    HEAD  357 

respiratory  center.  Death  occurs  in  from  one  to  five  days. 
Treatment  is  drainage  at  the  site  of  the  original  injury  or  opera- 
tion, but  rarely  does  the  patient  recover. 

Escape  of  Cerebrospinal  Fluid. — This  occurs  whenever  the 
dura  has  been  invaded.  In  compound  fracture  involving  the 
middle  fossa  its  escape  through  the  ear  is  commonly  noted. 
Following  operation,  the  amount  of  fluid  which  escapes  varies. 
After  several  days  the  discharge  lessens  and  finally  ceases.  Such 
wounds  must  be  kept  scrupulously  clean.  The  soaking  of  the 
dressing  with  the  cerebrospinal  fluid  will  necessitate  redressing 
at  sufficiently  frequent  intervals  to  keep  the  dressing  dry; 
usually  three  or  four  changes  of  dressing  daily  for  the  first  few 
days.  Drainage  must  be  absolutely  free.  Blockage  of  the 
drain  must  be  guarded  against.  The  wound-opening  must  be 
sufficiently  large  to  avoid  pressure  on  and  interference  with 
the  drainage  strips.  Several  strips  of  green-silk  protective 
serve  admirably  for  drains  in  such  cases.  Their  use  avoids  the 
possibility  of  blockage,  as  they  drain  by  capillarity  and  cannot 
absorb  the  discharge  and  become  clogged.  Upon  the  first 
symptom  of  change  in  the  condition  of  the  patient,  inspect  the 
wound  to  see  if  drainage  is  interfered  with  or  if  infection  has 
occurred. 

Hernia  cerebri  occurs  in  cases  in  which  the  dura  has  been 
opened  and  the  brain  injured.  It  is  caused  by  increase  in 
intracranial  pressure  due  to  increase  of  cerebrospinal  fluid  from 
irritation  of  the  meninges,  congestion  or  edema  of  the  brain. 
The  effects  depend  upon  the  function  of  the  part  of  the  brain 
which  is  prolapsed.  In  large  prolapses  through  comparatively 
small  openings  in  the  dura  the  part  prolapsed  becomes  doughy 
and  disintegrates.  In  case  the  opening  in  the  dura  is  large  the 
mass  is  not  so  liable  to  disintegration.  Infection  is  common. 
Treatment  consists 'in  supporting  the  mass  with  even,  gentle 
pressure.  Forcible  attempts  at  reduction  must  not  be  made. 
Cerebral  prolapse  occurring  after  operation  for  abscess  or  tumor 
is  due  either  to  a  reaccumulation  of  secretion  or  to  a  collection 
of  cerebrospinal  fluid  in  an  adjacent  ventricle.  In  case  of  the 
latter,  lumbar  puncture  is  recommended  (Kronlein).  In  fact, 
no  attempt  at  reduction  should  be  made  while  the  causes  pro- 


358  OPERATING    ROOM    AND    THE    PATIENT 

ducing  the  hernia  are  active.  If  no  infection  is  present  the 
skin  flaps  may  be  sutured  partially  over  the  herniated  brain, 
but  proper  drainage  for  the  escape  of  cerebrospinal  fluid  must 
be  provided.  Upon  the  subsidence  of  the  causes,  the  edema, 
the  meningeal  irritation  or  the  congestion,  the  prolapsed  portion 
will  recede  somewhat  into  the  cranial  cavity.  Gentle  reduction 
may  then  be  attempted  and  a  plastic  operation  done  to  cover 
in  the  defect,  but  drainage  must  be  provided  for. 

Hernia  occurring  in  silent  areas  of  the  brain  may  be  ampu- 
tated if  reduction  is  impracticable  and  if  plastic  operations 
for  covering  the  tumor  are  not  possible.  Infected  brain  tissue 
should  be  treated  conservatively,  using  gentle  irrigations  of 
saline  at  a  temperature  of  100°  F.  and  multiple  drains  of  green- 
silk  protective.  Hernia  cerebri  naturally  presents  a  very  bad 
prognosis. 

Hemorrhagic  Granuloma, — This  is  due  to  infection  arising 
usually  from  the  presence  of  splinters,  foreign  bodies,  or  other 
sources  of  irritation  occurring  in  an  open  wound  of  the  skull. 
The  granulations  spring  from  an  ulcerated  area  on  the  surface 
of  the  brain.  The  protruding  mass  may  be  the  size  of  a  walnut 
or  larger.  It  is  soft,  pulsating,  bleeds  readily,  and  may  contain 
small  suppurating  foci.  Microscopic  examination  may  be 
necessary  to  distinguish  it  from  hernia  cerebri.  Its  removal, 
together  with  splinters  of  bone,  foreign  body,  or  necrotic  tissue 
that  may  be  present,  is  usually  followed  by  cure. 

Wound  Healing  in  Bony  Defects,  Trephine  Openings. — Healing 
takes  place  by  dense  fibrous  tissue,  and  not  by  bone.  Conse- 
quently these  places  are  not  so  safeguarded  from  injury  as 
before.  Slight  blows  upon  such  defects  produce  disastrous 
results.  Exposure  to  the  sun  is  productive  of  intense  headache. 
If  the  opening  is  so  placed  the  hat  band  may  press  upon  it  and 
produce  discomfort.  Sudden  changes  of  the  position  of  the  body 
or  sudden  jars  may  produce  convulsions.  Such  defects  should 
be  protected  by  the  wearing  of  suitable  apparatus,  and  later 
when  the  patient's  condition  warrants  it  an  osteoplastic  flap 
should  be  so  placed  as  to  protect  the  opening.  The  introduc- 
tion of  silver,  gold  or  celluloid  plates  at  the  time  of  the  primary 
operation    has    not    proved    successful.     The    osteoplastic    flap 


OPERATIONS  UPON  THE  HEAD  359 

method  advocated  by  Konig  is  far  more  preferable.     Beck's 
method  of  periosteal  transplantation  has  shown  good  results. 

In  treating  the  wound  itself  antiseptics  should  not  be  employed. 
An  antiseptic  solution  should  never  be  allowed  to  come  in  contact 
with  brain  tissue.  It  is  permissible  if  infection  is  present  to 
use  normal  salt  solution  at  a  temperature  of  100°  F.  as  an  irriga- 
tion. In  general  in  drainage  cases  the  drain  is  removed  at  the 
end  of  twenty-four  or  thirty-six  hours.  Subsequently  the 
wound,  if  clean,  is  undisturbed  for  from  seven  to  ten  days, 
when  the  sutures  may  be  removed.  If  any  granulations  have 
developed  at  the  point  of  emergence  of  the  drains  these  are 
removed  with  the  curette.  Suppurating  wounds  are  dressed 
daily  with  large  absorbent  dressings. 

In  fractures  of  the  base  involving  the  anterior  fossa  the  nasal 
cavities  should  be  irrigated  daily  with  boric  acid  solution,  and 
packed  lightly  with  iodoform  gauze.  In  case  the  middle  fossa 
is  involved  and  there  has  been  escape  of  cerebral  fluid  from  the 
ear  the  same  treatment  by  irrigation  and  gauze  packing  is 
employed  to  guard  against  infection  through  these  channels. 

General  Rules  for  the  After-treatment  of  Intracranial  Opera- 
tions.— Each  case  must  be  carefully  and  constantly  observed  and 
all  symptoms  noted.  Complete  bodily  and  mental  rest  must  be 
enforced.  The  patient  is  kept  in  the  dorsal  position  with  the 
head  comfortably  supported.  Each  of  these  patients  should 
have  a  room  to  himself.  There  should  be  absolute  quiet  in 
the  room  and  the  room  should  be  kept  darkened.  The  patient 
should  never  be  left  alone.  Restraining  sheets  are  to  be  used 
for  restlessness.  It  is  best  not  to  stimulate  the  circulation. 
If  restlessness  is  marked,  morphin  should  be  administered  in 
sufficient  doses  to  ensure  rest.  Hyoscin  hydrobromate,  gr. 
1/120,  is  also  useful.  The  diet  should  be  liquid  and  easily 
assimilable.  Absolutely  no  alcohol  should  be  given.  The 
bowels  are  to  be  kept  open  by  laxatives,  preferably  salines, 
such  as  magnesium  sulphate.  In  case  involuntary  defecation 
and  urination  occur  the  patient  is  to  be  kept  scrupulously  clean 
to  avoid  decubitus.  A  colon  irrigation  once  a  day  is  beneficial. 
Overdistention  of  the  bladder  should  be  guarded  against,  and 
the  catheter  should  be  used  every  eight  hours  or  more  often  if 


360  OPERATING    ROOM    AND    THE    PATIENT 

necessar3^  An  ice  coil  is  to  be  kept  applied  to  the  head  and  an 
ice-bag  to  the  base  of  the  neck.  In  plethoric  cases  venesection 
is  of  value.  In  such  cases  venesection  quiets  the  patient,  the 
headache  disappears  and  they  fall  asleep.  On  the  occurrence 
of  any  complicating  symptoms  the  first  step  should  be  to  investi- 
gate the  condition  of  the  wound.  A  regular  record  of  the  blood 
pressure  should  be  kept  and  when  with  symptoms  of  congestion 
or  unconsciousness  this  falls  below  the  normal,  the  position  of  the 
patient  is  to  be  changed  and  the  head  lowered.  This  increases 
the  blood  pressure.  After  all  symptoms  have  subsided  a  more 
liberal  diet  may  be  allowed.  The  sitting  posture  should  be  grad- 
ually resumed.  The  patient  should  be  kept  under  observation  for 
many  months  and  the  mental  condition  noted.  Reading,  study- 
ing, and  application  of  the  mind  to  business  should  be  prohibited 
after  all  severe  injuries  or  operations.  The  patient  should  have 
open  air  exercise  and  suitable  amusement,  but  excitement  should 
be  avoided.  Travel  and  change  of  scene  serve  to  keep  the 
patient  from  worrying.  By  judicious  management  even  severe 
injuries  and  operations  will  result  favorably.  Later  Complica- 
tions.— After  all  such  operations  or  injuries  there  may  develop 
continuous  headache,  epilepsy,  idiocy,  loss  of  memory,  neuralgia, 
and  various  psychoses.  These  in  their  turn  require  treatment, 
but  their  consideration  here  would  lead  us  too  far  afield.  In  re- 
gard to  continuous  headache,  if  due  to  exudates,  potassium  iodid 
will  be  useful.  Persistent  paralyses  are  the  result  of  the  lesion  for 
which  the  operation  was  performed.  The  most  that  can  be  done 
is  in  preventing  contractures  as  much  as  possible  and,  in  some 
cases  of  isolated  paralyses  of  certain  sets  of  muscles,  doing  nerve 
or  tendon  transplantation. 

Mastoid  Operations.  Simple  Mastoid  Operation. — After  opera- 
tion the  cavity  is  lightly  packed  with  plain  gauze — tight  packing 
prevents  drainage,  interferes  with  granulation  and  may  cause  a 
temporary  facial  paralysis.  The  packing  is  undisturbed  for 
five  days,  unless  there  is  excessive  or  foul  discharge,  rise  of  tem- 
perature or  marked  pain. 

At  each  dressing  the  wound  is  lightly  packed — firm  packing 
prevents  the  filling  in  of  the  wound  by  granulations  and  by  so 
doing  the  wound  may  be  kept  open  for  months. 


OPERATIONS  UPON  THE  HEAD  361 

Irrigation  is  used  only  when  there  is  excessive  or  foul  secretion. 
Radical  Mastoid  Operation. — The  packing  consists  of  single 
strip  introduced  through  the  external  meatus,  the  posterior 
wound  having  been  sutured.  The  dressings  are  left  undisturbed 
for  a  week  unless  discharge  is  foul  or  profuse.  Sutures  are 
removed  in  seven  days.  The  cavity  of  the  ear  is  repacked 
every  second  day  for  the  succeeding  week  following  which 
the  packing  is  discontinued.  Ordinary  cleanliness  thereafter 
suffices.  The  cavity  is  not  irrigated  at  the  dressings  but  if, 
when  the  packing  is  left  out,  there  is  excessive  discharge 
irrigation  may  be  used.  As  a  rule  these  cases  do  better  if  kept 
perfectly  dry.  If  the  lateral  sinus  has  been  injured  the  bony 
cavity  is  tightly  packed.  The  wound  must  be  allowed  to  granu- 
late from  the  bottom.  If  the  sinus  has  been  injured  the  packing 
is  removed  very  carefully  at  the  end  of  forty-eight  or  seventy- 
two  hours  and  the  wound  firmly  repacked  if  bleeding  recurs. 
Such  a  wound  should  not  be  irrigated.  Subsequent  packings 
may  be  lightly  applied  if  no  hemorrhage  occurs.  In  all  cases 
the  external  ear  should  be  cleansed  daily.  Dermatitis  is  prone 
to  occur  if  irritating  discharges  are  left  on  the  skin.  Its  occur- 
rence calls  for  more  frequent  cleansing.  It  is  apt  to  occur  in 
children  if  iodoform  gauze  is  employed.  Caries. — If  the  open 
operation  has  been  a  complete  one,  i.e.,  if  all  carious  bone  has 
been  removed,  healing  should  be  complete  between  the  sixth 
and  eighth  week.  If  carious  bone  has  been  left  this  will  require 
subsequent  curettement  for  its  removal  before  healing  can 
occur. 

Complicating  Brain  Abscess. — There  is  localized  headache, 
with  disturbance  of  function  of  separate  portions  of  the  brain. 
The  fever  is  not  high  at  first.  Chills  are  at  first  absent.  There 
may  be  vertigo,  vomiting,  and  meningeal  irritability.  Irrita- 
bility or  convulsive  movements  of  groups  of  muscles  occur  if 
the  motor  area  is  involved.  The  symptoms  are  progressive, 
and  the  suppurative  collection  if  left  to  itself  in  time  will  infil- 
trate the  surrounding  brain  tissue,  or  reaching  the  surface  set  up 
a  meningitis.  The  abscess  is  usually  located  in  the  cerebellum 
or  temporo-sphenoidal  lobe.  Treatment. — Immediate  explora- 
tory craniotomy. 


362  OPERATING    ROOM    AND    THE    PATIENT 

Extradural  suppuration  may  occur,  or  meningitis  or  pachy- 
meningitis. There  is  steady  pain  either  in  the  temporo-sphenoidal 
region  or  temporo-parietal  region,  or  in  the  region  back  of  the 
mastoid  process.  This  pain  is  increased  by  percussion.  The 
overlying  soft  parts  may  be  edematous.  Treatment. — Removal 
of  sufficient  bone  to  provide  drainage. 

Sinus  phlebitis  is  characterized  by  sudden  high  temperature, 
irregular  fever,  rapid  pulse,  chills,  and  headache  at  the  site  of 
the  disease.  The  jugular  may  be  thrombosed  and  be  felt  as  a 
hard,  enlarged,  tender  cord.  Pyemia  quickly  follows.  Treat- 
ment.— Im.mediately  open  and  drain  the  lateral  sinus,  ligate  the 
jugular  below  the  thrombosis  and  excise  or  drain  it.  This  may 
be  done  in  time  to  prevent  pyemia.  It  should  be  done  even  if 
pyemia  is  already  present  in  order  to  prevent  further  manu- 
facture of  sepsis  in  the  original  focus. 

Intracranial  Neurectomies. — The  treatment  of  the  wound 
itself  is  that  for  aseptic  wounds  in  general.  If  tamponade  has 
been  used  to  control  hemorrhage  the  packing  is  carefully  removed 
at  the  end  of  forty-eight  hours  and  if  there  is  no  further  bleeding 
it  is  not  replaced.  In  such  cases  secondary  suturing  is  indicated. 
If  the  operation  has  been  successful  the  pain  disappears  either 
immediately  upon  recovery  of  the  patient  from  the  anesthetic, 
or  after  a  few  days.  In  such  cases  sensation  is  lost  in  the  region 
supplied  by  the  resected  or  excised  nerve  and  does  not  return 
completely.  The  extent  of  the  anesthesia  indicates  whether  all 
branches  of  that  particular  trunk  of  the  trigeminus  have  been 
sectioned.  Anastomotic  branches  between  the  trigeminus  and 
the  facial  may  result  in  rapid  restoration  of  sensation  in  the 
area  supplied  by  the  resected  nerve,  though  this  of  course  will 
not  be  complete.  Later  restoration  of  sensation  is  due  to  re- 
generation of  the  nerve-fibers.  Generally  speaking  the  longer 
the  anesthesia  persists  the  greater  the  probability  that  the  pain 
will  not  return. 

Trophic  Disturbances. — Keratitis  may  follow  resection  of  the 
trigeminus  or  intracranial  extirpation  of  the  gasserian  ganglion. 
The  nutrition  of  the  cornea  may  be  so  impaired  as  to  result  in 
suppuration  of  the  eyeball;  careful  cleansing  may  save  the  eye. 
The  eye  of  the  affected  side  should  be  irrigated  every  two  or 


OPERATIONS    UPON    THE    HEAD  363 

three  hours  with  warm  boric  acid  solution.  Later  a  protecting 
eye  shield  should  be  worn  to  prevent  entrance  of  foreign  matter. 

Secondary  hemorrhage  from  the  middle  meningeal  artery  may 
follow  in  cases  in  which  this  vessel  has  not  been  effectively 
ligated,  or  in  which  a  piece  of  gauze  or  plug  forced  into  the  fora- 
men spinosum  to  control  hemorrhage  from  this  vessel  has  become 
loosened.  The  symptoms  will  be  those  of  compression;  if  such 
occur  the  wound  must  be  opened,  the  clot  expressed  and  an 
attempt  made  to  secure  the  vessel.  Infection  of  the  wound  is 
almost  unknown.  In  those  cases  in  which  it  has  occurred  collec- 
tions of  pus  have  formed  in  the  retro-maxillary  fossa  and  the 
infection  has  been  transferred  to  the  meninges.  Small  areas  of 
bone  necrosis  may  cause  fistulse  until  the  necrosed  portion  has 
separated.  Usually,  however,  healing  is  uneventful.  Patients 
habituated  to  morphin  should  be  given  the  drug  in  sufficient 
doses  if  its  withdrawal  is  followed  by  untoward  symptoms. 

Operations  upon  the  Face. — Small  wounds  of  the  face,  such 
as  those  resulting  from  the  removal  of  wens  or  small  fibroid 
tumors  do  not  need  large  dressings.  The  blood  supply  of 
the  face  is  so  extensive  that  if  accurate  coaptation  of  the  wound 
edges  is  secured,  healing  rapidly  follows.  Moreover,  the  mobility 
of  the  parts  is  such  that  a  large  dressing  would  rather  irritate 
than  do  good  as  it  would  allow  the  wound  to  move  against  the 
dressing.  Again,  many  people  object  to  wearing  a  bandage 
upon  the  face,  it  is  difficult  to  apply  such  a  bandage  so  as  to  be 
comfortable,  and  in  many  cases  to  cause  their  proper  retention 
it  would  be  necessary  to  include  one  or  both  eyes.  In  wounds 
with  well-coapted  edges  such  dressings  are  unnecessary.  Paint- 
ing the  surface  for  a  space  of  one  inch  either  side  and  over  the 
wound  with  collodion,  or  a  dressing  of  collodion  and  cotton  ful- 
fils all  the  indications.  The  contraction  of  the  collodion  as  it 
dries  serves  to  still  further  relieve  any  tension  which  may  exist. 
It  is  of  course  desirable  to  have  as  insignificant  a  scar  as  possible 
on  the  face;  to  favor  this  the  young  scar  and  neighboring  skin 
may  be  painted  every  other  day  with  collodion  after  healing  has 
occurred  under  the  primary  dressing;  this  supports  the  scar  until 
firm  contraction  has  taken  place.  The  collodion  acts  also  by 
limiting  the  mobility  of  the  part  of  the  face  to  which  it  is  applied. 


364  OPERATION    ROOM    AND    THE    PATIENT 

In  cases  in  which  hemorrhage  is  to  be  expected  with  oozing, 
larger  dressings  must  be  applied  with  pressure.  Larger  dress- 
ings without  pressure  are  also  indicated  in  infected  wounds  or 
in  wounds  through  infected  tissues  in  which  the  dressing  must 
be  large  enough  to  receive  and  absorb  the  wound  secretions. 
If  the  eye  must  be  included  in  the  dressing  it  should  be  protected 
by  placing  over  the  closed  eye  a  small  compress  of  cotton,  and 
care  must  be  taken  not  to  apply  the  bandage  so  as  to  cause 
pressure.  When  such  dressings  are  applied  under  anesthesia, 
at  the  conclusion  of  an  operation  care  should  .be  taken  that  the 
eyelashes  are  not  turned  in,  also  that  there  is  no  conjunctivitis, 
the  result  of  ether  vapor.  If  conjunctivitis  is  present  the  dressing 
over  the  eye  should  be  moistened  with  a  saturated  solution  of 
boracic  acid.  At  each  redressing  the  eye  should  be  examined 
and  if  conjunctivitis  occurs  this  should  be  treated  by  frequent 
boracic  acid  irrigations  and  instillation  of  5  per  cent,  argyrol 
solution.  Eyes  not  the  seat  of  disease  can  be  kept  occluded  by  a 
dressing  for  a  long  time  without  fear  of  injury.  Should  soiling 
of  the  dressing  occur  it  should  be  changed  at  once,  otherwise 
conjunctivitis  may  occur.  Infected  wounds  in  the  neighborhood 
of  the  eye  should  be  dressed  frequently  and  the  eye  should  be 
irrigated  at  each  dressing,  otherwise  an  intense  conjunctivitis 
or  even  a  panophthalmia  may  result.  In  cases  of  infection 
near  the  eye  it  is  advisable  to  instil  a  drop  of  5  per  cent,  argyrol 
solution  into  the  eye  at  each  dressing.  If  intense  conjunctivitis 
does  occur  the  occlusive  dressing  should  be  discontinued  and 
energetic  treatment  of  the  conjunctivitis  at  once  instituted. 

Wounds  of  the  face  heal  rapidly  and  hence  the  sutures  may  be 
removed  early,  where  there  is  no  tension  in  forty-eight  hours,  and 
even  where  there  is  tension  in  five  to  six  days.  In  case  of  large 
defects  Thiersch  skin-grafting  should  be  used  early  to  prevent 
scarring.     The  final  cosmetic  effect  should  always  be  considered. 

Operations  on  the  Eyelids. — Following  plastic  operations 
upon  the  eyelids  the  lids  cannot  be  completely  opened;  as  soon 
as  wound  healing  occurs,  however,  the  retraction  of  the  scar 
allows  of  complete  opening  of  the  lids.  The  process  of  cicatriza- 
tion may  proceed  too  far  so  that  it  will  not  be  possible  to  com- 
pletely close  the  lids;  this  is  followed  by  conjunctivitis  and  even 


OPERATIONS  UPON  THE  HEAD  365 

ulcerative  keratitis  especially  if  the  lids  become  inverted  so  that 
the  eyelashes  rest  on.  the  cornea.  In  such  cases  the  eyelashes 
should  be  removed,  and  a  secondary  plastic  operation  performed. 
Edema  of  the  eyelid  which  sometimes  persists  following  plastic 
operations  is  treated  by  massage  and  graduated  pressure. 

Enucleation  of  the  Eye. — Very  few,  if  any,  of  the  major 
operations  require  less  subsequent  treatment,  or  cause  the 
surgeon  less  anxiety  than  enucleation  of  the  eyeball.  The 
mortality  is  very  slight,  not  more  than  one-tenth  to  one-fifth 
of  one  per  cent.  Meningitis  sometimes  follows  enucleation  for 
suppurative  panophthalmitis,  but  it  must  be  remembered  that 
meningitis  may  follow  this  condition  without  any  operation. 
Usually  there  is  but  little  hemorrhage,  although  profuse  and 
persistent  hemorrhage  occasionally  occurs  in  old  people  with 
atheromatous  and  dilated  blood-vessels  and  in  hemophiliacs. 
In  the  event  of  hemorrhage  the  socket  is  packed  with  gauze 
dipped  in  some  hot  antiseptic  solution,  preferably  bichlorid  1 
to  5000.  As  a  rule,  the  tampon  should  not  be  left  in  place 
more  than  half  a  day  because  the  difficulty  of  removal  increases 
hourly.  Before  attempting  to  remove,  douche  thoroughly 
with  boric  or  some  similar  solution,  as  hot  as  the  patient  can 
bear  and  then  make  very  gentle  traction  on  the  gauze.  This 
is  a  task  which  requires  time  and  patience.  The  routine  treat- 
ment after  enucleation  is  as  follows:  The  immediate  bleeding 
is  controlled  by  pressure  of  gauze  wrung  out  of  hot  water.  The 
tendons  and  conjunctiva  are  brought  together  by  sutures  and  a 
protective  bandage  is  applied.  To  lessen  the  ecchymosis  which 
always  follows  enucleation  the  nurse  is  directed  to  continue  the 
application  of  hot  boric  compresses  to  the  lids,  for  several  hours 
before  putting  on  a  bandage.  This  does  not  entirely  prevent 
ecchymosis  and  swelling,  but  tends  to  diminish  these  unpleasant 
complications. 

The  patient  is  kept  in  bed,  most  of  the  time  for  one  or  two 
days.  Once  or  twice  a  day,  for  a  week  or  more,  the  lids  are  to 
be  separated  and  the  parts  gently  cleansed  with  boric  acid  solu- 
tion. The  sutures  are  removed  on  the  fourth  day.  By  the  end 
of  the  third  week,  the  stump  has  sufficiently  healed  to  admit  an 
artificial  eye. 


366  OPERATING  ROOM  AND  THE  PATIENT 

A  slight  mucopurulent  discharge  may  persist  for  several  weeks. 
This  is  relieved  by  the  daily  instillation  of  two  or  three  drops 
of  a  solution  of  nitrate  of  silver,  one  grain  to  the  ounce. 

Plastic  Operations  upon  the  Nose. — As  a  rule  these  operations 
are  unsatisfactory  because  of  the  difficulty  in  gauging  the  correct 
size  of  the  flaps  needed.  To  be  even  moderately  successful 
osteoplastic  flaps  are  necessary.  Such  wounds  cannot  be  kept 
aseptic.  The  newly  formed  nasal  cavity  should  be  irrigated  every 
two  or  three  hours  with  saline  or  two  per  cent,  solution  of  boracic 
acid.  This  may  be  done  with  the  patient  in  Rose's  position,  or 
the  patient  may  be  sitting  up  and  leaning  forward  and  the  nose 
gently  irrigated  by  a  small  catheter  attached  to  a  douche  bag. 
By  this  means  septic  processes  may  be  averted.  The  wound 
itself  should  be  inspected  frequently  and  upon  evidence  of  lack 
of  circulation  in  any  part  of  the  flap  the  sutures  at  that  point 
should  be  removed.  Some  necrosis  of  the  flap  is  sure  to  occur 
but  by  careful  asepsis,  septic  infections  and  necrosis  due  to 
infection  will  be  limited.  When  such  operations  are  done  in 
several  stages  there  is  less  danger  of  circulatory  disturbances. 
Such  wounds  should  only  be  covered  loosely  with  gauze  and 
should  be  inspected  frequently  and  irrigated. 

Plastic  Operations  upon  the  Cheek. — -.Cicatricial  contraction 
may  be  so  pronounced  after  plastic  operations  upon  the  cheek 
as  to  prevent  the  patient  from  chewing.  The  lower  jaw  may 
become  fixed  by  the  contraction.  Months  of  treatment  are 
necessary  to  overcome  contractions  of  this  nature.  Treatment 
consists  in  gradually  stretching  the  sear  tissue.  This  is  accom- 
plished by  placing  a  dilating  gag  between  the  teeth  of  the  upper 
and  lower  jaw  and  gradually  opening  the  gag  so  as  to  force  the 
jaws  slowly  apart.  At  least  twenty  minutes  should  be  taken 
in  securing  even  a  small  amount  of  separation. 

Operations  on  the  Parotid  Gland.  Co7nplications. — Facial 
paralysis  follows  accidental  or  unavoidable  injury  to  the  facial 
nerve.  The  conjunctiva  of  the  paralyzed  eye  should  be  pro- 
tected and  cleansed.  Later,  if  anatomical  conditions  permit 
of  it,  nerve  anastomosis  may  be  done.  Parotid  fistula  may  fol- 
low partial  excision  of  the  gland  or  injury  to  the  parotid  duct 
and  require  a  plastic  operation  for  its  cure. 


OPEEATIONS  UPON  THE  HEAD  367 

Superficial  Neurectomies. — Following  subcutaneous  divisions 
of  the  infraorbital  nerve  within  the  infraorbital  fissure  hemor- 
rhage into  the  retrobulbar  tissue  may  result  from  injury  to  the 
infraorbital  artery.  The  retrobulbar  hemorrhage  causes  pro- 
trusion of  the  eyeball.  The  hemorrhage  is  usually  slight  in 
amount  and  resorption  of  the  extravasation  occurs. 

Plastic  Operations  on  the  Lip. — The  result  here  depends  upon 
the  amount  of  tissue  removed  and  the  variety  of  operation 
selected.  Following  removal  of  a  wedge-shaped  piece  healing  is 
rapid  and  deformity  slight.  The  mouth  which  is  small  at  first 
soon  becomes  larger,  though  of  course  it  never  assumes  the 
normal  proportions  except  in  those  cases  where  the  wedge-shaped 
piece  is  very  small.  In  case  it  was  not  possible  to  bring  the 
vermilion  edges  of  the  lip  in  apposition  in  operations  upon  the 
lower  lip  cicatricial  contraction  occurs  and  in  time  the  cica- 
tricial tissue  forming  the  lower  lip  presses  against  the  teeth  as  it 
retracts.  This  results  in  ulceration  of  the  scar  tissue  and  also 
allows  the  saliva  to  flow  from  the  mouth  continuously.  If  it 
was  not  possible  to  leave  any  mucous  membrane  on  the  lower 
lip  the  lip  retracts  in  the  direction  of  the  jaw;  this  exposes  the 
teeth  and  alveolar  process  of  the  lower  jaw.  The  deformity  is 
great. 

Secondary  operations  should  not  be  undertaken  for  at  least 
six  months  following  operations  for  epithelioma  of  the  lip,  as 
experience  shows  that  recurrence  in  these  cases  usually  takes 
place  in  the  first  few  months.  All  cases  of  epithelioma  of  the  lip 
should  be  examined  frequently,  at  least  once  every  two  weeks 
following  operation  in  order  that  recurrence  may  be  quickly 
recognized.  Cases  in  which  the  primary  operation  did  not 
include  the  removal  of  the  submental  and  submaxillary  glands 
even  though  apparently  unaffected  should  be  examined  once  each 
week. 

Harelip  Operations. — A  thin  layer  of  collodion  and  cotton  may 
be  applied  to  slightly  support  the  wound.  In  case  it  was 
necessary  to  make  lateral  incisions  to  relieve  tension,  these 
incisions  may  be  dressed  with  plain  gauze  held  in  place  by 
strips  of  adhesive  plaster.  As  the  line  of  the  incisions  made 
for  the  purpose  of  relieving  tension  is  in  the  cheek  and  the  naso- 


368  OPERATING    ROOM    AND    THE    PATIENT 

labial  fold  a  disfiguring  scar  is  not  apt  to  occur.  A  dumboll- 
sliaped  piece  of  adhesive  plaster  is  applied  in  such  a  manner  as  to 
force  the  cheek  in  the  direction  of  the  wound  and  so  avoid  tension. 
A  smaU  pledget  of  cotton  keeps  the  plaster  from  adhering  to  the 
lip.  The  hands  should  be  restrained  to  prevent  picking  at  the 
dressing.  The  patient  should  be  fed  by  spoon  or  soft  pharyn- 
geal tube  for  the  first  seven  days.  If  the  cicatrix  contracts  so 
that  a  depression  is  formed  in  place  of  a  slight  protuberance,  as 
in  the  normal  lip,  Nelaton's  operation  should  be  done;  if  on  the 
other  hand,  the  protuberance  is  prominent  after  cicatrization 
is  complete,  a  small  Y-shaped  piece  may  be  excised.  Care 
must  be  taken  to  accurately  coapt  the  vermilion  border.  If  the 
wound  heals  per  primam  the  superficial  sutures  are  removed 
on  the  third  to  the  sixth  day,  the  deep  sutures  on  the  seventh 
day.  In  adults  the  sutures  may  be  left  somewhat  longer.  If 
infection  has  occurred  the  suture  affected  should  be  removed. 
The  freshly  healed  wound  is  supported  by  a  strip  of  adhesive 
plaster.  This  is  shaped  narrow  at  the  point  where  it  rests  on 
the  wound,  broadening  out  over  the  cheeks.  The  cheeks  are 
pressed  toward  the  nose  and  the  adhesive  plaster  applied  with 
the  cheek  so  pressed  together  as  to  relieve  tension  on  the  wound. 
The  edges  of  the  adhesive  plaster  may  be  painted  with  collodion 
to  ensure  against  the  plaster  becoming  loosened.  In  case  healing 
has  in  part  occurred  through  granulation  and  the  final  cosmetic 
effect  be  disfiguring  a  secondary  operation  may  be  done.  Such 
an  operation,  however,  should  be  performed  after  from  four  to 
seven  years  in  the  case  of  young  children,  since  the  purpose  of  the 
primary  operation  is  to  further  the  nutrition  of  the  child  by 
increasing  its  ability  to  nurse.  Should  the  wound  fail  to  heal 
in  its  entirety,  the  surfaces  should  be  freshened  and  a  secondary 
suturing  be  performed.  If  there  is  marked  edema  of  the  wound 
edges  the  secondary  suturing  must  be  left  until  the  inflammation 
has  subsided. 

The  child  is  very  slowly  fed  by  spoon  or  pharyngeal  tube  for 
the  first  few  days.  If  spoon  feeding  is  done  too  fast  the  milk 
will  regurgitate  through  the  mouth  or  nose  and  some  may  enter 
the  larynx.  The  mother's  milk  should  be  used  when  possible. 
After  the  first  few  days  the  baby  may  be  allowed  to  nurse.     The 


OPERATIONS  UPON  THE  HEAD 


369 


first  bowel  movements  after  the  operation  will  contain  digested 
blood.  After  each  feeding  the  mouth  should  be  swabbed  out 
gently  with  small  pieces  of  gauze  wrung  out  of  a  2  per  cent, 
boracic  acid  solution.  Should  the  baby  cry  a  great  deal  and  by 
so  doing  endanger  the  primary  union  of  the  wound  a  few  drops 
of  paregoric  may  be  administered,  remembering  that  children 
bear  opium  very  poorly.  As  these  children  have  been  accus- 
tomed to  breathing  freely  through  the  mouth  some  embarass- 
ment  of  respiration  and  even  asphyxia  may  follow  the  closure 
of  the  defect  in  the  lip.  This  should  be  watched  for  and  on  its 
occurrence  the  attendant  is  instructed  to  open  the  baby's  mouth 
by  pressure  upon  the  lower  lip.  A  piece  of  adhesive  plaster 
may  be  used  to  depress  the  chin  and  to  keep  the  mouth  open 
but  this  becomes  easily  displaced.  The  sutures  are  removed 
in  three  to  six  days.  During  their  removal  tension  is  prevented 
by  pressing  the  cheeks  toward  each  other.  The  wound  is  dried, 
a  little  collodion  is  painted  on  and  a  dumbell  strap  applied. 
This  strap  is  renewed  as  soiled.  Support  of  this  kind  should  be 
afforded  for  three  weeks. 

After-treatment    of    Operations    on  the  Nose,  Frontal  Sinus, 
Antrum  and  Cavity  of  the  Mouth. — In  the  after-treatment  of 

operations 

upon     the 

nose      the 

special 

points    to 

be  borne  in  mind  are  the  displacement  of 

the  bony  or  cartilaginous  structures,  hemo- 

stasis,  the  prevention  of  infection  and  the 

prevention  of  adhesions. 

Prevention  of  Hemorrhage. — After  the  re- 
moval of  mucous  polypi  bleeding  ceases 
spontaneously,  as  a  rule.  If  slight  bleeding 
persists  this  is  controlled  by  packing  lightly 
with  dry  gauze;  if  the  bleeding  point  comes  readily  into  view  a 
strip  of  gauze  is  packed  directly  against  it,  otherwise  the  end 
of  the  strip  of  gauze  is  carried  deep  into  the  nose  and  the  strip 
packed  into  it  layer  by  layer  until  the  entire  nasal  cavity  is 

24 


Fig.  180.— Bellocq's 
cannula  with  the 
spring  carrier  pro- 
j  e  c  t  e  d  .  (Fowler's 
Surgery.) 


370  OPERATING    ROOM    AND    THE    PATIENT 

filled;  tlie  other  end  of  tlie  gauze  is  then  tucked  out  of  the  way 
just  within  the  anterior  nares.  If  such  a  packing  does  not  con- 
trol the  hemorrhage  it  will  be  necessary  to  pack  the  posterior 
nares  as  well.  A  Bellocque  cannula  (Fig.  180)  is  passed  through 
the  nose  into  the  pharynx,  the  end  of  the  cannula  is  then 
withdrawn  through  the  mouth  and  to  it  is  fastened  a  tampon 
of  gauze.  A  small  thread  is  also  fastened  to  the  tampon  for 
subsequently  removing  it.  By  drawing  on  the  cannula  the 
tampon  is  drawn  into  the  posterior  nares  and  the  threads 
which  fasten  it  to  the  end  of  the  cannula  are  drawn  out  through 
the  affected  nostril.  The  proper  placing  of  the  tampon  is 
further  facilitated  by  pressure  of  the  finger  against  the  tampon 
in  the  pharynx.  After  the  posterior  tampon  is  firmly  fixed  in 
place  the  anterior  nares  are  packed  as  described  above. 

The  tampon  is  removed  at  the  end  of  twenty-four  to  forty- 
eight  hours;  by  this  time  the  secretions  of  the  mucous  membrane 
of  the  nose  and  naso-pharynx  will  have  softened  the  tampon 
so  that  there  is  slight  adhesion  of  it  to  the  mucous  membrane. 
Care  should  be  used  in  removal  so  as  not  to  excite  renewed 
hemorrhage. 

Bemay's  Plugs. — These  are  made  of  compressed  cotton  in 
several  sizes  conforming  to  the  natural  curve  of  the  anterior 
nares.  They  are  gently  pushed  into  position  while  dry,  the 
oozing  from  the  bleeding  point  saturates  them  and  causes  them 
to  swell  and  so  arrests  hemorrhage.  At  the  end  of  forty-eight 
hours  such  a  plug  may  be  removed  piece-meal. 

Prevention  of  Adhesions. — T\'Tien  the  nasal  cavity  is  very  narrow 
adhesions  between  the  two  surfaces  tend  to  form.  The  raw 
surfaces  should  be  gently  separated  with  a  flat  probe  and  aristol 
applied  by  an  atomizer,  A  strip  of  green-silk  protective  is  laid 
on  the  raw  surfaces  and  held  in  place  by  a  light  packing.  This 
is  renewed  daily  and  the  nose  gently  irrigated  with  Dobell 
solution. 

Prevention  of  Displacement. — ^Plugging  of  the  anterior  nares 
is  used  following  operations  upon  the  bony  septum  and  following 
osteoplastic  operations  upon  the  nose.  The  packing  need  not 
be  so  tight  as  that  for  the  prevention  of  hemorrhage,  for  if  the 
parts  have  been  properly  placed  there  is  slight  danger  of  dis- 


OPERATIONS  UPON  THE  HEAD  371 

placement.  Following  removal  of  dead  bone  in  syphilitic  and 
tuberculous  necrosis  nasal  splints  (Fig.  181)  are  useful,  not  so 
much  for  the  purpose  of  preventing  deformity,  as  to  insure  a 
free  breathing  space. 

Infection. — On  account  of  the  impossibility  of  perfect  asepsis 
and  the  large  number  of  germs  which  have  their  normal  habitat 
in  the  nose  wound  disturbances  by  infection  are  common  but 
fortunately  rarely  serious.  Wounds  of  the  nose  heal  under  a 
scab.  Erysipelas  is  much  rarer  now  than 
formerly,  due  to  improved  antiseptic 
methods;  more  rare  still  is  progressive 
phlegmon.  When  either  of  these  infec- 
tions occur  death  may  result  through  ex- 
tension of  the  inflammation  to  the  ethmoid 
and  from  there  to  the  meninges,  or  by 
thrombophlebitis  and  pyemia,  or  decom-       YTg.    1 8 1 Asch's 

posed  products  of  putrefaction  may  be  vulcanized  tube  splint. 
.         .      -^  .  .  "^  (iowlers  burgery.) 

inspired    and     septic    pneumonia    result. 

They  cannot  always  be  prevented  by  the  most  careful  prepara- 
tion nor  by  care  in  the  operation. 

Disadvantages  of  Nasal  Tamponade. — Packing  of  the  nares 
causes  an  annoying  full  sensation  in  the  head.  The  patient  is 
compelled  to  breathe  through  the  mouth  and  speech  becomes 
nasal  in  tone.  The  pressure  may  be  severe  enough  to  cause 
actual  pain.  Secretions  collect  behind  the  tampon  and  result 
in  a  rise  of  temperature.  In  case  of  a  tamponade  of  the  posterior 
nares  the  soft  palate  may  be  injured  and  this  may  result  in  some 
slight  temperature.  As  a  result  of  the  presence  of  the  tampon 
in  the  posterior  nares  slight  inflammation  of  the  tonsils  may 
persist  for  a  few  days;  this  as  a  rule  disappears  rapidly.  From 
the  above  it  is  evident  that  tamponade  should  not  be  used  unless 
strictly  indicated. 

Complication  by  Otitis  Media. — Inflammation  following  opera- 
tions upon  the  nose  may  spread  to  the  naso-pharynx  and  through 
the  Eustachian  tubes  to  the  middle  ear.  The  first  symptom  will 
be  sharp  pain  in  the  ear;  this  may  be  treated  by  leeches  in  front 
of  the  tragus,  by  local  applications  of  cocain,  or  if  the  pain  is 
more  severe,  by  injections   of   morphin.     Usually  the   process 


372  OPERATING    ROOM    AND    THE    PATIENT 

subsides  rapidly  though  sometimes  it  goes  on  to  suppuration. 
The  ear  should  be  examined  fi'equently  and  destruction  of  the 
drum  membrane  forestalled  by  an  early  paracentesis.  As  soon 
as  any  symptoms  of  ear  invasion  take  place  the  tampon  should 
be  removed  from  the  nose  and  the  nose  douched  several  times  a 
day  with  warm  boric  acid  solution;  the  mucous  membrane  should 
be  carefully  cleansed  and  all  inspissated  secretions  removed. 

General  Rules.— In  all  cases  the  patient  should  be  warned  not 
to  scratch  the  nose  or  pick  at  it,  and  in  children  the  hands 
should  be  muffled  in  such  a  manner  as  to  prevent  this.  Douches 
are  not  used  unless  indicated  by  excessive  secretion,  retention 
of  secretion  or  rise  in  temperature.  They  should  not  be  given 
in  the  first  twelve  hours  for  fear  of  causing  bleeding.  In 
douching  the  nose  the  stream  should  be  directed  upward  and 
not  backward;  otherwise  the  fluid  may  be  forced  into  the 
Eustachian  tubes.  If  a  chronic  catarrhal  condition  of  the 
mucous  membrane  persists  the  mucous  membrane  should  be 
painted  with  a  1  or  2  per  cent,  nitrate  of  silver  or  1/2  to  1 
per  cent,  solution  of  alum  or  a  solution  of  tannin  may  be 
snuffed  up  the  nose. 

Opening  of  the  Frontal  Sinus. — Too  early  closure  must  be 
avoided.  The  cure  of  a  suppurative  condition  requires  weeks 
and  sometimes  months;  this  is  only  obtained  by  free  exit  for  the 
secretions.  The  first  few  dressings  are  done  every  day  by 
packing  the  wound  with  plain  gauze;  following  this  balsam-of- 
Peru  gauze  should  be  used  and  the  sinus  washed  out  with  a 
mild  antiseptic  solution.  The  interior  of  the  sinus  will  be 
filled  up  at  first  by  the  swollen  mucous  membrane;  after  the 
infection  has  subsided  the  external  wound  may  be  kept  open 
by  a  rubber  drainage  tube;  the  sinus  need  not  be  packed.  A 
mild  antiseptic  and  astringent  solution  should  be  used  several 
times  daily  to  irrigate  the  cavity  and  to  reduce  the  swollen 
mucous  membrane  lining  it.  When  this  is  accomplished  the 
communication  with  the  nose  is  reestablished.  When  the 
sinus  drains  readily  through  the  nose  and  the  character  of  its 
secretion  is  such  as  not  to  clog  up  the  opening  into  the  nose 
the  external  or  operative  wound  may  be  allowed  to  close.  Upon 
the  removal  of  the  drainage  tube  this  will  close  rapidly.     There 


OPERATIONS  UPON  THE  HEAD  373 

will  be  some  adhesion  of  the  scar  to  the  bone.  Sounds  should  be 
passed  from  within  the  nose  into  the  sinus  to  insure  the  patency 
of  the  canal.  If  catarrh  of  the  duct  persists  the  wound  must  be 
kept  open  and  the  sound  passed  from  within  the  sinus.  In 
obstinate  cases  it  may  be  necessary  to  open  the  entire  canal. 

Opening  of  the  Antrum  of  Highmore. — The  same  principles 
hold  good  for  the  treatment  of  empyema  of  the  antrum,  whether 
opened  through  the  nose,  through  the  alveolar  pi'ocess,  or 
through  the  anterior  wall;  the  after-treatment  is  the  same, 
the  drainage  opening  must  be  kept  open  by  a  stiff-walled  drain- 
age tube  to  prevent  too  early  closure.  After  opening  through 
the  anterior  wall  the  cavity  may  be  tamponed  with  plain  gauze 
for  twenty-four  hours  to  arrest  bleeding;  following  this  the 
cavity  should  be  irrigated  every  two  or  three  hours,  at  first  with 
boric  acid  solution,  later  with  a  weak  solution  of  nitrate  of  silver. 
If  the  amount  of  dischai'ge  is  large  one-half  strength  peroxid 
of  hydrogen  may  be  used  to  irrigate,  followed  by  stronger 
solutions  of  nitrate  of  silver.  The  normal  opening  into  the 
nose  would  only  allow  of  slight  drainage,  therefore  the  opera- 
tive opening  should  be  kept  open  until  discharge  has  ceased 
and  the  inflammation  of  the  mucous  membrane  entirely  sub- 
sided. In  draining  such  a  case  through  the  alveolar  process  a 
special  apparatus  may  be  fastened  to  an  adjoining  .tooth,  the  ap- 
paratus consisting  of  a  gold  tube  of  small  caliber  having  fitted 
to  it  a  stopper  which  is  held  in  place  by  a  bayonet  joint;  this 
prevents  entrance  of  food  into  the  antrum  and  allows  of  ready 
removal.  For  purposes  of  cleansing  the  antrum  such  a  tube, 
as  well  as  any  tube  draining  the  antrum,  should  not  project 
beyond  the  level  of  the  floor  of  the  antrum. 

Dangers  after  Operations  upon  the  Mouth. — The  principal 
danger  is  loss  of  blood  during  the  operation,  next  the  inter- 
ference with  respiration  by  the  entrance  of  blood  into  the  air- 
passages,  and  finally  septic  pneumonia  from  inspiration  of  blood 
or  secretions. 

Bronchopneumonia. — This  is  probably  always  due  to  in- 
spiration of  particles  of  food,  or  vomitus,  or  decomposed  wound 
secretions.  The  danger  increases  in  proportion  to  the  amount  of 
disturbance  of  function  of  the  muscles  of  the  tongue,  palate  and 


374  OPERATING    EOOM    AND    THE    PATIENT 

pharynx,  therefore  such  a  complication  is  more  apt  to  follow 
operations  upon  the  lower  jaw,  tonsU  and  floor  of  the  mouth, 
than  for  removal  of  the  upper  j  aw. 

To  prevent  particles  of  food  from  entering  the  larynx  the 
patient  should  be  fed  through  a  stomach  tube.  It  may  be 
passed  either  through  the  nose  or  the  mouth.  After  very  ex- 
tensive operations  upon  the  floor  of  the  mouth  owing  to  the 
amount  of  oozing  or  wound  discharge  it  may  be  necessary  to 
leave  a  stomach  tube  and  also  a  tracheotomy  tube  in  place  and 
pack  the  pharynx  solidly  with  gauze;  this  is  very  annoying  to 
the  patient  and  causes  a  flow  of  saliva  and  mucus;  it  should, 
therefore,  only  be  used  after  very  extensive  operations,  and  only 
during  the  first  few  days. 

Phlegmonous  inflammation  of  the  tissues  of  the  neck  may 
complicate  tonsillotomy  or  other  operations  in  the  mouth  and 
pharynx.  There  is  marked  swelling  and  redness  of  the  mucous 
membrane  overlying  the  infected  area  internally,  while  exter- 
nally the  overlying  skin  presents  a  red  and  brawny  appearance, 
pitting  deeply  on  pressure.  There  is  pain  on  deglutition,  and 
breathing  may  be  interfered  with  by  the  intense  edema.  Owing 
to  the  virulent  nature  of  the  infection,  it  is  accompanied  by  high 
temperature,  rapid  pulse  and  general  malaise.  Unless  prompt 
treatment  is  instituted,  edema  of  the  glottis  will  ensue.  In- 
cisions may  be  made  through  the  mouth  or  from  without.  A 
point  of  fluctuation  is  sought  for  and  drainage  instituted  by  the 
nearest  route.  Very  little  free  pus  is  found  as  a  rule,  perhaps 
only  a  dram.  Should  the  symptoms  continue,  additional  pus 
foci  must  be  searched  for  and  drainage  provided  for.  Scarifica- 
tion of  the  mucous  membrane  will  relieve  pain  and  lessen  edema. 
If  the  case  is  seen  late  it  may  be  necessary  to  resort  to  tracheot- 
omy. Such  abscesses  sometimes  open  spontaneously  into  the 
pharynx.  There  is  then  danger  of  suffocation  or  death  from 
foreign  body  pneumonia.  If  pus  has  not  been  evacuated  though 
a  search  has  been  made,  the  infection  may  in  a  few  hours  or 
days  find  its  way  out  through  the  exploratory  incision.  The 
abscess  cavity  and  infected  area  should  be  cleansed  every  three 
hours  with  peroxid  of  hydrogen  and  then  irrigated  with  a  mild 
alkaline  antiseptic  solution. 


OPEEATIONS    UPON    THE    HEAD  375 

Ranula  Operations. — After  extirpation  of  the  ranula  or  other 
tumor  or  cyst  of  the  floor  of  the  mouth  that  part  of  the  wound 
over  which  the  mucous  membrane  has  not  been  sutured 
should  be  packed  with  gauze;  this  may  remain  in  place  from 
forty-eight  to  seventy-two  hours.  Following  this  the  mouth 
should  be  frequently  irrigated  with  a  mild  weak  antiseptic 
solution;  healing  rapidly  ensues. 

Tongue-tie.' — After  this  slight  operation  there  is  usually  little 
bleeding  but  occasionally  oozing  will  persist.  As  the  patient  is 
usually  an  infant  even  the  loss  of  a  slight  amount  of  blood  must 
be  immediately  controlled.  If  an  examination  of  the  wound 
shows  a  bleeding  vessel  this  is  ligated.  Persistent  oozing  is 
controlled  by  drawing  the  tongue  forward,  elevating  it,  packing 
a  small  piece  of  dry  gauze  against  the  oozing  area  and  still  holding 
the  tongue  forward  depressing  it  to  make  pressure  upon  the 
packing.     Two  or  three  minutes  pressure  is  usually  sufficient. 

Adenoids. — The  patient  is  quieted  and  told  to  avoid  coughing, 
sneezing  or  snuffling.  The  head  is  kept  high.  Bleeding  varies 
greatly;  except  in  cases  between  the  ages  of  ten  and  eighteen 
it  is  rarely  severe.  It  occurs  more  often  if  shreds  have  been  left. 
Should  the  bleeding  be  prolonged  direct  pressure  is  made  with 
a  curved  stick  sponge.  Usually  two  minutes  pressure  is  sufficient; 
if  not,  the  naso-pharyngeal  space  is  tamponed.  Usually,  how- 
ever, the  hemorrhage  ceases  spontaneously.  An  occasional 
fatal  case  is  reported.  The  patient  is  instructed  not  to  swallow 
any  blood  as  this  is  apt  to  occasion  vomiting  and  so  cause  a 
recurrence  of  the  hemorrhage.  If  there  has  been  much  bleeding 
the  nose  and  naso-pharynx  become  filled  with  blood  clot.  In 
such  a  case  twenty-four  hours  after  the  operation  nasal  irrigation 
of  warm  boric  acid  solution  may  be  employed  to  wash  away  the 
clots.  Clotted  blood  left  in  the  naso-pharynx  may  become  in- 
fected and  lead  to  middle  ear  complications.  Middle  ear  and 
Eustachian  tube  complications  are  fortunately  rare  and  are  more 
apt  to  follow  bad  technic  at  the  operation. 

Usually  no  after-treatment  is  necessary.  Healing  is  complete 
in  from  eight  to  foui'teen  days. 

Tonsillectomy. — The  patient  is  to  be  watched  until  all  hemor- 
rhage has  ceased.     Hemostasis  is  spontaneous  in  most  cases.     In 


376  OPERATING    ROOM    AND    THE    PATIENT 

hemophiliacs  and  in  cases  of  injury  to  the  larger  branches  of  the 
tonsillar  artery  bleeding  is  severe.  In  such  cases  pressure  by  a 
stick  sponge  must  be  kept  up  for  a  few  minutes.  If  this  does  not 
suffice  pressure  may  be  applied  with  a  Mikulicz  clamp;  or 
an  attempt  may  be  made  to  ligature  the  bleeding  points  or  the 
pillars  of  the  fauces  may  be  sutured  over  a  gauze  sponge. 
Tongue  movement  and  coughing  are  to  be  avoided  in  all  cases 
for  the  first  few  hours.  In  the  cases  which  ooze  small  pieces 
of  ice  are  retained  in  the  mouth  and  ice  water  slowly  sipped 
for  ten  minutes  at  a  time.  The  movements  of  obstreperous 
patients  must  be  controlled.  Gargling  does  not  help  in  the 
slightest. 

Course  of  the  Wound.- — The  stump  of  the  tonsil  will  become 
covered  with  a  grayish-white  deposit  of  fibrin  which  disappears 
in  about  a  week.  In  rare  cases  a  streptococcus  inflammation  will 
complicate. 

Wound  Treatment. — Usually  no  wound  treatment  is  required. 
For  purposes  of  mouth  cleanliness  gargles  of  a  mildly  alkaline  anti- 
septic solution  may  be  employed,  but  this  rarely  reaches  the 
wound  surface.  This  is  to  be  kept  clean  by  spraying  every  three 
or  four  hours  with  peroxid  of  hydrogen  after  the  first  twenty-four 
hours.  For  the  first  twenty-four  hours  rest  is  required  for  the 
pharynx  and  tongue.  It  is  not  necessary  to  keep  the  patient  in 
bed  longer  than  twenty-four  hours  in  ordinary  cases.  If  severe  in- 
flammatory symptoms  develop,  as  evidenced  by  intense  redness 
of  the  tonsillar  stump,  pharynx,  pillars  of  the  fauces  and  uvula, 
accompanied  by  fever  and  swelling  of  the  glands  in  the  neck, 
the  patient  is  placed  in  bed,  the  pharynx  and  wound  surfaces 
are  sprayed  thoroughly  and  frequently  with  peroxid  of  hydrogen. 
Ice  externally  to  the  neck  is  grateful  to  the  patient.  For  the 
flrst  twenty-four  hours  give  ice-cold  drinks  and  ice  by  the 
mouth.  Ice  cream  and  ices  will  be  acceptable,  particularly  to 
cnildren.  For  the  second  and  third  day  give  fluid  diet,  not 
necessarily  cold.  A"s  soon  as  pain  on  swallowing  has  stopped 
full  diet  may  be  resumed. 

Lymphadenitis  may  accompany  infection  in  the  mouth  and 
naso-pharynx.  If  the  infection  be  severe  the  cervical  lymph 
glands  draining  the  infected  area  become  enlarged.     Perilym- 


OPERATIONS  UPON  THE  HEAD  377 

phadenitis  accompanies  this.  Should  suppuration  ensue  the 
glands  affected  are  to  be  promptly  incised  and  drained. 

The  voice  after  removal  of  the  tonsils  becomes  deeper  in  vol- 
ume. This  must  be  considered  before  removing  the  tonsils  of 
patients  whose  living  depends  on  the  quality  of  their  voices. 

Peritonsillar  Abscess. — Following  incision  and  digital  curettage 
of  the  infected  area  the. resulting  cavity  is  gently  irrigated  every 
few  hours  with  a  mildly  antiseptic  alkaline  solution  using  a  blunt- 
pointed  hard  rubber  syringe.  As  the  inflammation  subsides 
the  irrigation  is  done  less  frequently.  The  mouth  is  kept  clean 
by  frequent  rinsing.  The  patient  is  kept  on  a  diet  of  soft  food 
as  long  as  swallowing  is  painful. 

Retropharyngeal  abscess  is  incised  widely  through  the  cavity 
of  the  mouth  at  as  low  a  level  as  possible  to  prevent  the  formation 
of  a  pocket.  Care  must  be  taken  to  avoid  strangulation  from 
the  pus,  especially  in  children.  Inspiration  of  pus  leads  to 
bronchopneumonia.  The  danger  of  reinfection  by  the  bacteria  of 
the  mouth  and  naso-pharynx  is  slight  but  the  mouth  and  throat 
should  be  rinsed  frequently  with  an  antiseptic  solution.  The 
opening  is  to  be  dilated  daily  with  anatomical  forceps.  In  large 
cavities  the  entrance  of  food  is  prevented  by  the  use  of  the  stom- 
ach tube.  Should  the  cause  of  the  infection  reside  in  caries  of 
the  cervical  vertebrae,  an  external  incision  must  be  made  and  the 
cause  treated.  Edema  of  the  glottis  is  a  common  complication 
in  neglected  cases  and  those  not  drained  properly. 

Tonsillectomy  for  Carcinoma. — This  leaves  a  much  greater 
area  for  infection.  If  removed  from  within,  the  wound  is  to  be 
treated,  as  in  amputation  of  the  tongue  from  within  the  mouth 
and  as  in  tonsillectomy.  Complications  are  more  apt  to  ensue. 
//  removed  from  without,  external  pharyngotomy ,  the  severed 
stylohyoid  is  sutured,  the  retracted  muscles  returned  to  their 
normal  relation  and  the  greater  part  of  the  wound  sutured.  A 
tight  packing  is  introduced  into  the  wound,  sufficient  to  entirely 
close  off  the  cavity  of  the  pharynx  and  the  gauze  strip  led  out 
at  the  lower  angle  of  the  wound.  This  is  left  in  situ  for  from 
four  to  seven  days  unless  its  removal  is  indicated  by  some  of 
the  complications  before  noted.  On  removal  the  wound  will  be 
found  in  a  surprisingly  healthy  condition,  considering  the  prox- 


378  OPERATIXG    ROOM    AXD    THE    PATIENT 

imity  of  the  pharynx.  For  the  most  part  the  wound  will  have 
healed  b}'  primary  union.  The  wound  is  gently  irrigated  and 
packed  with  a  small  amount  of  gauze.  This  is  renewed  every 
forty-eight  hours  until  healing  is  complete.  If  resection  of  the 
lower  jaw  has  been  done  in  order  to  gain  more  space  the  after- 
course  may  be  complicated  by  necrosis,  and  a  second  operation 
may  be  necessary  to  remove  necrotic  bone  before  the  resulting 
fistula  will  close.  Feeding  is  conducted  as  in  amputation  of  the 
tongue  and  resection  of  the  lower  jaw. 

Uranoplasty.  Staphylorrhaphy. — In  adults  the  mortality  from 
wound  complications  in  these  operations  is  small.  In  children, 
under  four  years,  the  mortality  is  high.  In  all  cases  the  healing 
process  may  be  so  complicated  by  infection  or  giving  way  of 
sutures  as  to  partially  or  completeh"  negatize  the  object  of  the 
operation.  During  the  first  few  hours  after  the  operation  the 
head  should  be  kept  lowered  and  turned  to  one  side  to  afford 
ready  outlet  for  secretions  and  blood.  There  is  always  some  ooz- 
ing from  the  raw  surfaces  of  the  flaps  and  from  the  lateral 
incisions  made  for  the  purpose  of  relieving  tension.  The  blood 
may  be  expectorated,  swallowed,  or  in  rare  cases  in  young  chil- 
dren, maybe  drawn  into  the  lungs  by  forcible  inspiration  and  set 
up  a  pneumonia. 

Feeding  by  mouth  should  not  be  begun  until  all  danger 
of  post-anesthetic  vomiting  is  passed.  Saline  enemata  are 
given  for  the  first  twenty-four  to  forty-eight  hours.  At  first 
the  food  consists  of  milk,  either  plain  or  modified.  The  food 
should  be  introduced  far  back  on  the  side  of  the  tongue,  or 
should  be  given  through  a  tube.  After  the  fourth  day  in  the 
case  of  older  children  small  quantities  of  farinaceous  food  may 
be  added  to  the  milk  diet.  Xo  solid  food  should  be  given  for 
at  least  two  weeks.  The  patient  should  be  kept  quiet,  talking, 
laughing  or  crying  should  be  avoided.  In  young  children 
excessive  crying  will  cause  the  flaps  to  separate.  It  may  be 
necessary  to  administer  opiates  to  prevent  children  from  crying. 
In  young  children  the  arms  should  be  fastened  to  prevent  picking 
at  the  mouth;  this  is  best  accomplished  by  splinting  the  elbows. 
In  this  way  free  motion  of  the  hands  is  possible  but  the  mouth 
cannot  be  reached.     Older  children    should    be  instructed    to 


OPERATIONS  UPON  THE  HEAD  379 

keep  the  tongue  away  from  the  roof  of  the  mouth.  The  stitches 
should  be  removed  in  ten  days.  If  union  is  not  firm  they  may  be 
allowed  to  remain  for  from  four  to  seven  days  longer.  The 
wound  should  be  inspected  daily  but  should  not  be  interfered 
with.  In  young  children  if  examination  of  the  mouth  causes 
crying,  it  will  be  better  to  leave  the  patient  undisturbed.  If 
inflammation  develops  a  mild  antiseptic  solution  should  be 
sprayed  gently  on  the  palate  and  through  the  nose.  Unless 
inflammation  develops  no  spraying  is  necessary.  No  peroxid 
spray  should  be  used  at  any  time. 

Complications. — Hemorrhage  is  controlled  by  pressure  with 
dry  sponges  at  the  time  of  operation.  Sponges  wrung  out  of 
hot  water  should  not  be  employed  as  the  excessive  heat  may 
injure  the  flaps.  Sometimes  the  source  of  bleeding  wiU  be  found 
to  be  a  vessel  not  completely  severed  in  one  of  the  lateral  incisions 
used  for  the  purpose  of  relaxation  of  the  flaps.  If  the  bleeding 
recurs  when  the  patient  has  recovered  from  the  anesthetic  the 
parts  should  be  cleansed  of  the  blood  clot  by  spraying  with  ice- 
cold  boric  acid  solution.  The  removal  of  the  clots  is  further 
facilitated  by  gently  sponging.  Pressure  with  ice-cold  sponges 
may  be  tried.  Usually  this  treatment  is  effectual;  if  not  the 
patient  must  be  anesthetized  and  the  source  of  hemorrhage 
located,  and  if  possible  a  ligature  applied.  If  the  source  cannot 
be  identified  the  post-palatine  canal  should  be  sought  for  and 
plugged  with  Horsley's  wax.  This  is  forced  into  the  canal  with 
a  small  probe.  Packing  the  lateral  incisions  with  small  pieces  of 
gauze  will  sometimes  suffice  for  hemorrhage  at  these  points. 
If  these  means  are  not  sufficient  it  may  be  necessary  to  trache- 
otomize  the  patient  and  pack  the  cavity  of  the  mouth  firmly.  It 
must  be  remembered  that  young  children  bear  the  loss  of  blood 
very  poorly. 

Failure  of  Union  may  Occur. — This  is  commonly  due  to  necrosis 
of  a  portion  of  the  flaps.  The  necrosis  may  be  due  to  trauma- 
tism inflicted  during  efforts  to  control  hemorrhage,  to  infection, 
a  strangulation  of  the  tissues  through  too  tightly  applied  sutures; 
the  relaxation  incisions  may  not  have  been  liberal  enough  to 
prevent  tension  of  the  flaps;  or  the  paring  of  the  flap  may  not  have 
been  completely  accomplished.     This  latter  is  apt  to  happen 


380  OPERATING  ROOM  AND  THE  PATIENT 

if  the  strip  of  mucous  membrane  is  not  removed  in  one  piece. 
The  coaptation  may  not  have  been  accurate,  the  flaps  may  have 
been  injured  after  the  operation  by  the  patient  chewing  some 
hard  article  of  food,  bacteria  from  the  mouth  or  nose  may  at- 
tack a  flap,  excessive  crying  or  vomiting  may  cause  the  sutures 
to  loosen  or  to  pull  out  entirely,  coryza  may  develop  and  the 
inflammation  extend  to  the  flaps.  Rarely  will  the  flaps  become 
gangrenous  and  slough  away  entirely.  The  loss  of  tissue  may 
be  so  great  as  to  render  subsequent  operations  impossible.  The 
cleft  may  be  thus  made  considerably  larger  than  before  the 
operation. 

The  naturally  poor  blood  supply  of  the  transplanted  flaps  is 
in  all  operations  still  further  interfered  with  by  the  approximating 
sutures  so  that  there  is  always  some  danger  of  necrosis.  The 
operation  may  be  done  in  two  stages  to  insure  the  utmost 
stability  to  the  flaps  by  secondary  suturing  or  a  staphylorrhaphy 
may  be  done  as  a  secondary  procedure.  As  a  rule,  the  flaps  unite 
for  the  most  part,  though  here  and  there  there  may  be  a  small  gap 
which  fills  in  later,  the  lateral  incisions  granulate  and  quickly 
become  covered  with  mucous  membrane,  the  main  object  of 
operation,  that  of  preventing  the  passage  of  food  into  the  nasal 
cavity  will  usually  have  been  obtained.  If  infection  occurs  pus 
collects  upon  the  upper  surfaces  of  the  flap,  but  as  drainage  is 
free  there  is  no  abscess  formation  and  the  fever  incident  to  such 
infection  disappears  on  the  occurrence  of  granulation.  Such 
infections  may  result  in  septic  pneumonia  through  aspiration. 
When  infection  occurs  there  wifl  be  noticed  a  slightly  fetid  odor 
to  the  breath,  the  patient  will  refuse  nourishment  on  account  of 
the  pain. 

Treatment  of  Complications. — The  cause  of  any  separation  of 
flaps  should  be  determined.  If  mechanical  and  due  to  the 
stitches  or  to  not  sufficient  relaxation  this  may  be  remedied 
by  loosening  the  stitches  and  putting  in  new  sutures,  or  in  the 
latter  event  by  increasing  the  length  of  the  lateral  incisions. 
At  the  point  where  union  fails  from  necrosis  secondary  suturing 
should  not  be  done  until  the  wound  is  clean  and  granulation  is 
well  established.  Small  defects  will  heal  in  by  granulation  with- 
out subsequent  operation,  larger  defects  may  at  times  be  closed 


OPERATIONS  UPON  THE  HEAD  381 

by  paring  of  the  edges  and  secondary  suturing.  If  the  parts  are 
not  sufficiently  relaxed  to  accomplish  this  a  secondary  flap- 
splitting  operation  must  be  employed.  Secondary  operations  in 
cases  in  which  there  has  been  much  sloughing  are  not  so  apt  to  be 
successful  as  primary  operations;  in  such  cases  it  would  be  better 
to  fit  a  plate.  Septic  inflammation  in  flaps  is  treated  by  spraying 
the  parts  every  two  hours  with  a  mildly  antiseptic  solution. 
Gangrenous  and  ulcerated  areas  may  be  gently  touched  with  a 
10  per  cent,  chlorid  of  zinc  solution. 

In  necrosis  of  the  flap  great  care  should  be  used  in  preserving 
the  posterior  sutures  and  these  should  not  be  removed  except 
their  usefulness  has  entirely  been  negatized.  If  they  are  re- 
moved union  may  be  despaired  of  for  the  flaps  speedily  retract. 
If  they  are  left  in  place  even  if  they  serve  no  further  purpose  than 
to  hold  the  flaps  posteriorly  in  apposition  they  will  serve  to  allow 
of  granulations  springing  up  between  the  edges  of  the  flap  an- 
teriorly and  some  union  being  effected. 

Older  patients  should  be  taught  to  breathe  through  the 
nose  with  the  mouth  closed.  Elocution  lessons  should  be 
taken  to  develop  the  soft  palate  and  so  get  rid  of  the  nasal 
quality  of  speech  which  these  patients  have  acquired.  The 
development  of  normal  speech  depends  upon  the  anatomical 
condition  of  the  parts  alone.  In  cases  in  which  the  soft  palate  is 
deficient,  in  order  to  overcome  the  nasal  tone  of  the  voice  a 
mucous  membrane  flap,  with  the  base  left  attached,  may  be  dis- 
sected from  the  posterior  wall  of  the  pharynx  and  united  to  the 
pared  posterior  edge  of  the  hard  palate  or  the  rudimentary  soft 
palate.  The  after-treatment  will  be  the  same  as  in  simple 
uranoplasty  and  staphylorrhaphy.  Great  care  must  be  ex- 
ercised to  keep  the  cavity  of  the  nose  clear  of  mucus,  as  drainage 
through  the  pharynx  is  interfered  with  by  the  mucous  membrane 
flap.  After  several  weeks  or  months  the  base  of  the  flap  is 
separated  from  the  posterior  pharyngeal  wall.  This  operation 
gives  good  functional  results.  Labials  and  sibilants  will  be 
particularly  hard  for  these  patients  to  pronounce.  Should  the 
operation  fail  completely  through  extensive  sloughing  of  the 
flaps  nothing  remains  but  the  proper  fitting  of  an  obturator  to 
cover  in  the  defect. 


382  OPERATING    ROOM    AND    THE    PATIENT 

Amputation  of  the  Tongue. — The  after-treatment  varies 
with  the  amount  of  the  tongue  removed  and  the  operative 
technic  employed.  If  the  anterior  half  or  two-thirds  of  the 
tongue  or  the  lateral  haK  of  the  tongue  is  removed  through 
the  mouth,  treatment  is  comparatively  simple  and  consists 
mainly  in  keeping  the  mouth  free  from  secretions.  The  tongue 
stump  heals  rapidly.  Feeding  is  done  as  in  case  of  resection 
of  the  lower  jaw.  If  preliminary  ligation  of  the  lingual  vessels 
has  been  done  the  neck  wound  is  treated  on  general  principles. 
If  the  operation  has  been  more  extensive  and  part  of  the  floor 
of  the  mouth  removed  as  well  through  an  incision  below  the 
lower  border  of  the  inferior  maxilla,  with  or  without  resection 
of  this  bone,  the  wound  is  drained  from  below  and  treated  as 
outlined  for  resection  of  the  lower  jaw,  and  is  liable  to  similar 
complications.  If  glands  have  been  removed  from  the  neck, 
the  resulting  wounds  are  treated  on  general  principles.  A 
preliminary  tracheotomy  may  have  been  performed.  Though  a 
fistula  follows  the  more  extensive  operations,  this  will  at  most 
only  necessitate  a  second  plastic  operation.  Infection  of  the 
tongue  will  result  in  rapid  swelling,  on  account  of  the  numerous 
lymphatic  vessels  of  that  organ.  This  can  only  be  prevented 
by  rigid  cleansing  of  the  mouth.  All  carious  teeth  should  have 
been  filled  or  removed  prior  to  operating.  The  teeth  are  kept 
clean  by  rubbing  them  three  or  four  times  daily  with  cotton 
sticks  dipped  in  antiseptic  solutions,  and  the  mouth  cavity 
cleansed  by  frequent  sprayings.  Should  infection  occur  the 
tongue  stump  is  to  be  freed  of  any  constricting  sutures  and 
thoroughly  sprayed  with  peroxid  of  hydrogen,  with  the  patient 
leaning  forward  to  facilitate  free  exit  of  the  antiseptic.  Gan- 
grenous areas  are  to  be  touched  daily  with  10  per  cent,  chlorid 
of  zinc. 

Edema  of  the  glottis  may  follow,  and  if  a  preliminary  tracheot- 
omy has  not  been  done,  death  from  suffocation  is  an  immediate 
danger.  The  only  remedy  is  rapid  tracheotomy.  In  cases  in 
which  edema  of  the  glottis  is  expected,  a  tracheotomy  set 
should  be  placed  near  the  bedside.  Feeding  is  done  with  the 
stomach  tube,  pharyngeal  tube  or  by  rectum  until  the  patient 
can  control  the  movements  of  the  tongue.     Speech. — If  less  than 


OPERATIONS  UPON  THE  HEAD  383 

two-thirds  of  the  tongue  or  only  the  lateral  half  has  been  re- 
moved, impairment  of  speech  will  be  astonishingly  slight.  If 
the  entire  tongue  has  been  excised  to  the  level  of  the  epiglottis, 
the  tongue  sounds  are  lost  and  the  patient  must  substitute  lip 
sounds  for  these.  In  these  cases  if  the  pillars  of  the  fauces  have 
been  sutured  over  the  base  of  the  tongue  speech  is  fairly  well  pre- 
served as  a  natural  moving  diaphragm  results. 

Extraction  of  Teeth. — The  surgeon  is  rarely  called  upon  to 
extract  teeth.  Hemorrhage  following  teeth  extraction  usually 
subsides  spontaneously;  if  not  the  alveolar  cavity  may  be 
packed  with  plain  gauze  or  cotton;  subsequently  the  mouth 
should  be  cleansed  frequently  with  a  mild  antiseptic  mouth  wash. 
Alveolar  parodontitis,  parulis  or  even  a  suppurative  osteomyelitis 
may  follow  removal  of  a  tooth.  Such  complications  are  more 
apt  to  occur  if  the  tooth  was  extracted  while  suppuration  was 
already  present.  In  such  a  case  the  cavity  should  be  packed 
with  iodoform  gauze  and  repeated  irrigations  used.  After 
extraction  of  upper  molars  the  possibility  of  opening  of  the 
antrum  of  Highmore  should  be  borne  in  mind.  This  need 
occasion  no  alarm;  the  mouth  should  be  kept  thoroughly  cleansed 
with  an  antiseptic  wash.  Should  infection  occur  opening  and 
draining  of  the  antrum  may  be  necessary. 

Parulis. — As  soon  as  fluctuation  occurs  an  incision  should  be 
made.  If  symptoms  of  osteomyelitis  develop,  fever,  intense 
pain,  swelling,  redness  and  apparent  thickening  of  the  bone,  the 
bone  should  be  trephined. 

Resection  of  the  Alveolar  Process. — A  plain  gauze  tampon 
should  be  used  to  control  oozing;  this  is  removed  at  the  end  of 
twenty-four  hours  and  the  mouth  kept  clean  with  repeated 
irrigations. 

Fractures  of  the  Jaw. — All  cases  which  are  not  readily  retained 
in  position  by  ordinary  bandaging  should  have  an  interdental 
splint  made.  The  patients  are  fed  by  passing  a  small  rubber 
catheter  along  between  the  teeth  and  the  cheek  and  behind  the 
last  tooth.  The  same  means  are  used  to  frequently  irrigate  and 
cleanse  the  mouth.  In  compound  fractures  circumscribed 
suppuration  at  the  seat  of  fracture  is  common.  This  is  treated 
by  frequent  spraying  of  the  infected  cavity.     If  the  pus  tends 


384 


OPERATING  ROOM  AND  THE  PATIENT 


to  extend  toward  the  neck  a  counter-opening  and  free  drainage 
must  be  made.  In  compound  fractures  it  is  common  for 
sequestra  to  be  thrown  off;  it  is  best  to  allow  this  to  occur 
naturally  and  not  to  hasten  it  by  frequent  curettings. 

The  Interdental  Splint. — When  this  method  of  treatment  can 
be  made  available,  it  is  by  far  the  best  method  for  fractures  of 
the  mandible.  The  patient's  mouth  and  teeth  are  carefully 
cleansed  beforehand.  It  may  be  necessary  to  administer  a 
general  anesthetic.  An  impression  is  taken  as  for  upper  and 
lower  dentures,  no  attempt  being  made  to  reduce  the  fragments. 
The  method  of  procedure  is  as  follows:  The  ordinary  modeling 
cups  of  the  dentist  are  filled  with  yellow  beeswax;  the  latter  is 
gradually  heated  over  an  alcohol  flame  and  worked  with  the 
fingers  until  it  is  soft.     Impressions  of  the  upper  and  the  lower 


■ 

■ 

n 

■■j 

'  "i 

^^^B 

5Ssl_L__ 

naJ                 ^id 

H 

gHUHl      i 

^^^^* 

i 

^^^ 

^gijgg^ 

gb^ 

^5 

I^H 

IH 

Fig.   182. — The  articulator.      (Fowler's  Surgery.) 

teeth  are  taken  and  the  wax  allowed  to  harden.  A  plaster-of- 
Paris  cast  of  the  upper  jaw  is  then  made  and  this  is  secured  by 
means  of  plaster  cream  to  the  upper  part  of  an  articulator 
(Fig.  182).  In  the  same  way  a  cast  of  the  lower  jaw  is  made, 
the  site  of  the  fracture  recognized  and  marked,  and  the  cast 
sawed  in  two  at  that  point  in  a  line  corresponding  as  nearly  as 
possible  with  the  fracture. 

The  two  pieces  of  the  cast  of  the  lower  jaw  are  now  brought 
into  their  proper  relation  so  that  the  lower  and  upper  teeth 
articulate  normally;  they  are  then  fastened  together  by  means 
of  plaster  cream  on  the  lower  arm  of  the  articulator  (Fig.  183). 


OPERATIONS    UPON    THE    HEAD 


385 


On  this  model  of  the  reduced  fracture  an  interdental  splint  of 
vulcanite  (Fig.  184)  is  made  by  a  mechanical  dentist.  The 
splint  is  trimmed  so  as  not  to  impinge  on  the  gums.  In  placing 
the  splint  in  position  it  is  first  adjusted  to  the  upper  teeth;  the 


Fig.  183. — Plaster-of -Paris  models  of  upper  and  lower  teeth  molded  in 
the  articulator.  A,  Cast  of  fracture  of  the  lower  jaw;  B,  the  same  after  the 
site  of  the  fracture  has  been  sawed  across  and  the  normal  relations  of  the 
parts  restored.      (Fowler's  Surgery.) 

teeth  of  the  lower  jaw  are  now  forced  into  the  recesses  made  for 
them  on  the  corrected  model,  the  displacement  thus  being 
rectified.  Suitable  bandages  (Barton's  or  a  modification  thereof) 
are  applied  so  as  to  hold  the  lower  jaw  firmly  against  the  splint. 
The   latter   is  worn  for  from  thirty  to  fifty  days. 

The  interdental  splint  is 
suitable  for  the  treatment  of 
fractures  through  the  dental 
arch.  Various  slight  modifi- 
cations of  its  form  may  be 
rendered  necessary  for  feed- 
ing purposes  so  as  to  take 
advantage  of  any  gaps  in  the 
teeth  that  may  exist. 

In  fractures  in  the  region 


Fig.   184. — Interdental   splint  of  vul- 
canite.     (Fowler's  Surgery.) 


of  the  molar  teeth  special  care  must  be  exercised  not  to 
separate  the  jaws  any  wider  than  is  absolutely  necessary  in 
the    application   of   the   splint,  lest  failure  of  the  front  teeth 


25 


386 


OPERATING    ROOM    AXD    THE    PATIENT 


to  articulate  vrhen  the  healing  is  completed  result.  Here 
the  portion  of  the  splint  interposed  between  the  teeth  should  be 
as  thin  as  is  consistent  with  strength,  for  it  is  evident  that  the 
greater  the  separation  of  the  jaws,  the  greater  will  be  the  stress 
on  the  posterior  fragment.  The  thin  gold  splint  of  Ottolengui 
(Fig.  185)  answers  the  purpose  best  under  these  circumstances. 


P-«v. 

M 

■ 

T 

-^ 

34 

J 

^K^**          A 

--_^    - 

_^ 

Tl, 

sr^j    jf    1 

---H^ 

na 

mi 

§B 

Fig.  185. — Gold  interdental  splint.  For  use  in  cases  of  fracture  posterior 
to  the  last  molar.  A,  The  sphnt ;  B,  the  spUnt  shown  in  place  on  the  plaster 
model.     (Fowler's  Surgery.) 

If  the  fracture  is  in  front  of  the  bicuspid  teeth,  a  short  splint 
or  a  simple  capping  of  the  lower  teeth  in  cases  where  there  is 
little  deformity  will  fulfil  all  requirements. 

In  cases  of  double  fracture  an  interdental  splint  is  indispen- 
sable; if  one  break  is  at  or  near  the  angle,  the  splint  should  be  as 
thin  as  possible  so  as  to  avoid  increasing  the  deformity  at  this 
point. 

Dislocation  of  the  Jaw. — Dislocations  of  the  jaw  are  prone  to 
recur  and  therefore  a  retaining  bandage  should  be  applied  for 
five  to  seven  days  following  the  dislocation.  After  this  the  pa- 
tient should  be  warned  not  to  yawn  or  laugh  immoderately. 
In  recurrent  dislocations  of  the  jaw  the  retaining  bandage  should 


OPERATIONS    UPON    THE    HEAD  387 

be  kept  in  place  for  a  longer  time,  the  patient  should  not  be 
allowed  solid  food,  or  to  chew  vigorously  for  several  weeks. 
If  in  spite  of  this  treatment  the  dislocation  recurs  an  operation 
for  the  formation  of  a  more  prominent  eminentia  articularis 
is   indicated. 

Resection  of  One-half  of  the  Upper  Jaw. — The  primary  dressing 
is  placed  in  the  wound  at  the  time  of  operation,  directly  the 
individual  bleeding  points  have  been  secured.  This  dressing 
consists  of  a  strip  of  gauze,  either  iodoform  or  zinc  oxid,  four 
inches  wide  and  of  sufficient  length  to  fill  the  entire  wound  cavity. 
This  is  very  tightly  packed  to  prevent  hemorrhage  or  the  entrance 
of  extraneous  matter  from  the  mouth  or  naso-pharynx,  and  is 
retained  in  position  by  suturing  the  skin  flaps  over  it.  The 
line  of  incision  is  painted  with  collodion.  Primary  union  is 
the  rule  in  the  skin  incisions  and  a  linear  scar  will  result,  except 
in  those  portions  of  the  skin  flap  where  an  angle  exists.  In 
those  cases  in  which  a  vertical  incision  joins  a  horizontal  incision 
below  the  orbital  arch,  the  resulting  skin  angle  is  likely  to  necrose 
and  may  result  in  a  persistent  fistula  communicating  with  the 
cavity  of  the  mouth.  To  avoid  this,  sutures  should  not  be  placed 
too  near  such  an  angle.  The  wound  at  this  point  should  be 
inspected  at  the  end  of  twenty-four  hours.  If  the  flap  at  this 
point  shows  any  lack  of  circulation,  one  or  more  sutures  in  the 
neighborhood  are  to  be  removed.  Aside  from  this  angle,  fre- 
quent inspection  of  the  wound  is  to  be  deprecated  here  as  else- 
where. The  remaining  sutures  are  removed  on  from  the  fifth 
to  the  seventh  day. 

If  'preliminary  ligation  of  the  external  carotid  has  been  done 
bleeding  may  be  so  slight  as  not  to  require  wound  packing. 
Such  cases  require  very  frequent,  careful  and  gentle  douching 
and  spraying  of  the  nose,  the  mouth  and  wound  surfaces. 

Nourishment. — The  patient  must  be  fed  by  the  stomach  tube  for 
the  first  four  days.  A  small  quantity  of  sterile  water  may  then  be 
given,  and  if  this  be  swallowed  without  gagging,  fluid  diet  may  be 
begun  by  mouth.  If  a  large  amount  of  muscular  tissue  has  been 
removed,  gagging  may  persist  and  the  use  of  the  stomach  tube 
be  required  for  as  long  a  period  as  two  weeks.  Semi-solid  and 
finally  solid  food  may  be  given,  beginning  in  the  third  week.     Care 


388  OPERATING    ROOM    AND    THE    PATIENT 

of  the  Mouth  and  Nose. — The  mouth,  nose  and  throat  should  be 
sprayed  with  weak  antiseptic  alkaline  solutions  every  two  or  three 
hours.  Spraying  is  to  be  done  gently  to  prevent  gagging  and  to 
be  continued  at  frec^uent  intervals  until  the  wound  cavity  is 
healed.  Position  of  the  Patient. — Here,  as  in  all  operations  in 
which  saliva  may  enter  a  wound,  the  patient  should  lie  on  the 
healthy  side  to  facilitate  the  flow  of  saliva  away  from  the  wound. 
The  ivound  cavity  is  kept  clean  by  the  tight  packing  preventing 
the  entrance  of  saliva  or  liquid  food.  This  primary  packing  is  left 
in  situ  for  eight  days,  at  the  end  of  which  time  granulations  have 
been  established,  and  the  dangers  arising  from  secondary  hemor- 
rhage and  infection  are  practically  passed.  If,  previous  to  this 
time,  the  outer  layers  of  the  packing  have  become  soaked  by 
saliva  or  food,  the  soiled  portion  may  be  removed  without  dis- 
turbing the  main  portions  of  the  packing.  Even  this  will  hardly 
be  necessary  before  the  fourth  day  if  the  directions  have  been 
strictly  adhered  to  for  keeping  the  mouth  and  nose  clean.  The 
removal  of  the  packing  is  effected  without  difficulty.  If  done 
gradually,  no  bleeding  will  result,  or  at  most  a  slight  oozing. 
The  portion  of  the  gauze  in  contact  with  the  wound  surface  will 
be  found  fresh  and  clean.  No  irrigation  should  be  used  at  this 
dressing.  The  wound  cavity  is  repacked,  but  not  so  tightly  as 
before,  and  this  process  is  repeated  every  forty-eight  hours.  At 
the  third  and  at  subsequent  dressings  the  wound  cavity  is  to  be 
irrigated  with  an  anti-septic  solution,  preferably  a  weak  solution 
of  potassium  permanganate.  The  amount  of  packing  is  decreased 
as  granulation  rapidly  proceeds.  It  is  only  by  the  strictest  clean- 
liness that  a  healthy  condition  of  the  cavity  can  be  maintained. 
After  the  primary  tight  packing  has  been  removed,  bacteria,  as 
well  as  saliva  and  particles  of  food,  readily  finds  access  to  the 
wound.  The  granulations  are  apt  to  become  gray  and  sluggish, 
and  require  curetting  or  painting  with  nitrate  of  silver  solution. 
If  the  cavity  is  neglected,  a  very  foul  discharge  will  result.  After 
the  second  week,  as  granulations  proceed  more  rapidly,  irrigation 
and  packing  are  to  be  more  frequent.  The  w^ound  cavity  may 
take  weeks  or  months  in  completely  cicatrizing,  the  epithelium 
of  the  neighboring  mucous  membrane  slowly  creeping  over  the 
granulating  surface.     If  the  wound   secretions   seem   dammed 


OPERATIONS  UPON  THE  HEAD  389 

back  by  the  packing,  this  is  to  be  left  out  for  several  days  and 
more  energetic  means  employed  to  clean  the  cavity.  The 
patient  is  instructed  to  syringe  out  the  cavity  after  each  meal  and 
at  frequent  intervals. 

Complications. — In  cases  in  which  hemostasis  has  not  been 
carefully  practised  or  in  which  the  gauze  packing  has  not  been 
methodically  placed  or  has  become  displaced  through  the  restless- 
ness of  the  patient,  a  profuse  primary  hemorrhage  may  result. 
This  is  to  be  watched  for  in  the  first  forty-eight  hours  and  a  prompt 
repacking  of  the  cavity  done. 

Secondary  hemorrhage  is  not  apt  to  occur  in  aseptically  treated 
wounds.  Erysipelas  was  formerly  greatly  dreaded,  but  its 
occurrence  at  the  present  time  is  almost  a  surgical  curiosity. 
Edema  of  the  soft  parts  may  occur  soon  after  the  operation,  but 
need  occasion  no  anxiety.  Loosening  the  retaining  bandage  is 
all  that  is  necessary  for  the  comfort  of  the  patient.  Occurring 
later  it  indicates  a  septic  condition  of  the  wound  or  a  retention 
of  secretion,  which  more  rigid  wound  cleansing  will  cause  to 
subside. 

Deformity. — The  skin  scar  is  hardly  noticeable  if  primary 
union  has  taken  place.  The  amount  of  falling  in  of  the  cheek 
will  depend  upon  the  amount  of  tissue  removed.  If  the  opera- 
tion has  been  a  subperiosteal  one,  the  resulting  deformity  will  be 
comparatively  slight.  If  practically  only  a  skin  flap  has  been 
preserved,  a  correspondingly  greater  deformity  will  result.  If 
the  orbital  plate  is  removed,  the  eye  will  be  drawn  downward. 
Operations  which  destroy  the  nerve  supply  of  the  cheek  will  neces- 
sarily result  in  loss  of  expression  upon  the  affected  side.  Con- 
junctivitis or  even  panophthalmia  with  loss  of  the  eye  may  occur. 
Prosthesis. — Prosthetic  apparatus  should  not  be  employed  until 
cicatrization  has  been  effected.  Their  earlier  use  interferes  too 
greatly  with  wound  healing.  Such  an  apparatus  will  support  the 
cheek  and  obviate  the  deformity  from  the  sinking  in  of  the  soft 
parts.  Care  should  be  taken,  however,  that  no  irritation  is  caused 
by  pressure,  more  especially  in  cases  in  which  the  operation 
has  been  done  for  malignant  disease. 

Speech. — By  reason  of  the  loss  of  the  alveolar  process  and  the 
free  communication  with  the  nasal  cavity,  articulation  will  be 


390  OPERATING    ROOM    AND    THE    PATIENT 

greatly  embarassed.  A  good  prosthetic  apparatus  will  cause 
these  patients  to  speak  more  distinctly.  Vision. — If  the 
operative  procedure  has  involved  the  removal  of  the  inferior 
orbital  wall,  the  eyeball  will  sink  downward.  Its  displacement 
will  be  further  increased  by  the  cicatricial  contraction  of  the  wound. 
As  a  consequence  the  muscular  apparatus  of  the  eye  is  affected, 
in  some  cases,  to  the  extent  of  causing  double  vision.  Ocular 
circulation  and  innervation  may  be  so  affected  as  to  cause  loss  of 
the  eye.  This  may  be  due  in  part  to  injury  to  the  infraorbital 
and  facial  nerves.  The  primary  symptoms  of  conjunctivitis 
should  be  carefully  watched  for.  Treatment  can  only  be  of 
avail  when  initiated  in  the  early  stages;  when  such  complica- 
tions ensue  the  case  should  be  referred  to  an  experienced 
ophthalmologist.  Recurrence  of  malignant  disease  should  be  ex- 
pected and  its  appearance  should  be  met  by  prompt  local  in- 
terference when  this  is  possible,  or  at  least  by  such  local  and 
general  treatment  as  will  most  relieve  the  patient.  In  general  it 
may  be  stated  that  the  more  radical  the  original  operation,  the 
more  extended  will  be  the  period  of  quiesence. 

Resection  and  Disarticulation  of  the  Lower  Jaw. — On  account 
of  the  invasion  of  the  floor  of  the  mouth,  defects  in  speech  and 
difficulty  in  eating  and  in  keeping  the  mouth  clean  are  greater 
after  operations  upon  the  lower  jaw  than  is  the  case  in  operations 
upon  the  upper  jaw.  The  tongue  muscles  being  divided,  the 
movements  of  the  tongue  are  difficult  and  painful.  For  this 
reason  saliva  and  wound  secretions  more  easily  pass  over  along- 
side the  tongue  and  enter  the  glottic  opening,  and  foreign-body 
pneumonia  more  readily  occurs.  Infection  of  the  deep  tissues  of 
the  neck  is  also  prone  to  develop,  owing  to  the  increased  difficulty 
in  keeping  the  wound  surface  clean.  Dressing. — The  primary 
dressing  varies  with  the  operative  technic  employed.  With 
'preliminary  tracheotomy  the  wound  treatment  is  simplified.  In 
such  cases  the  wound  may  be  sutured  to  a  great  extent  and  the 
remainder  tightly  packed  with  gauze,  the  ends  of  the  gauze 
strips  emerging  so  as  not  to  interfere  with  the  tracheotomy  tube. 
This  dressing  may  remain  in  place  for  forty-eight  to  seventy-two 
hours,  or  may  be  removed  only  on  the  occurrence  of  retention  of 
secretion  or  upon  its  becoming  soaked  with  saliva  and  wound 


OPERATIONS  UPON  THE  HEAD  391 

secretions.  The  care  of  the  tracheotomy  tube  is  outlined  on 
p.  398.  In  these  cases  it  may  be  removed  as  soon  as  granulation 
of  the  wound  is  established.  Dressings  are  renewed  daily  after 
the  first  dressing.  Irrigation  may  be  practised  if  wound  secre- 
tion is  profuse.  The  flow  of  saliva  may  be  controlled,  in  part, 
by  atropin  in  sufficient  doses  to  produce  dryness  of  the  mouth. 
If  a  preliminary  tracheotomy  has  not  been  done,  the  care  of  the 
wound  is  more  difficult.  It  is  impossible  to  wall  off  such  a 
wound  from  the  cavity  of  the  mouth  and  nose.  This  is  at- 
tempted by  partial  suturing  of  the  mucous  membrane  of  the 
cheek  to  that  of  the  floor  of  the  month  and  gauze  drainage,  but  a 
communication  will  always  persist.  The  drains  emerge  below. 
A  copious  outer  dressing  of  plain  gauze  serves  to  catch  the 
saliva  and  wound  secretions.  This  outer  dressing  is  changed 
as  often  as  soiled,  about  every  six  hours  for  the  first  day,  less 
frequently  thereafter.  If  it  has  not  been  possible  to  suture  the 
mucous  membrane  of  the  cheek  to  that  of  the  floor  of  the  mouth 
at  least  in  part,  the  entire  wound  cavity  is  crowded  with  gauze. 
This  must  be  changed  after  the  first  twenty-four  hours  and  a 
new  packing  introduced  daily.  In  addition  the  wound  is  to  be 
irrigated  with  mild  alkaline  antiseptic  solution.  Another  and 
more  preferable  method  of  wound  treatment  consists  in  suturing 
as  much  of  the  mucous  membrane  as  possible,  not  employing 
packing  and  applying  an  external  dressing  to  catch  the  secretions. 
Atropin  is  administered  to  keep  the  mouth  as  dry  as  possible  for 
the  first  three  days.  The  patient's  mouth  is  kept  free  from 
secretions  by  constant  swabbing  with  cotton  sticks  until  the 
effects  of  the  anesthetic  and  of  the  operation  have  passed  off, 
when  the  patient  is  bolstered  up  in  bed  to  allow  the  wound 
secretion  to  drain  immediately  into  the  outer  gauze  dressing. 
This  is  changed  every  two  hours  and  the  wound  frequently 
irrigated  with  saline  solution  until  granulation  is  established. 
The  patient  may  be  placed  on  his  back,  with  the  head  turned  to 
one  side  while  sleeping.  The  possibility  of  closing  the  mouth 
cavity  by  suturing  the  mucous  membrane  greatly  decreases  the 
danger  of  foreign-body  pneumonia.  Bolstering  the  patient  up 
also  decreases  this  danger,  and  also  that  of  infection  of  the 
neighboring  cellular  tissues.     Should  retention  of  secretion  occur, 


392  OPERATIXG    ROOM    AND    THE    PATIENT 

it  should  be  met  l^y  more  rigorous  disinfection  and  the  removal 
of  any  sutures  which  may  be  at  fault.  Should  infection  of  the 
cellular  tissue  of  the  neck  complicate,  free  incision  and  adec^uate 
drainage  must  be  afforded. 

Suffocation.— This  is  a  real  and  constant  danger  in  those 
cases  in  which  section  of  the  geniogiossi  muscles  makes  possible 
the  closure  of  the  glottic  opening  by  the  falling  back  of  the 
tongue.  This  danger  will  continue  until  wound  healing  has 
advanced  sufficiently  to  afford  a  fixed  point  of  attachment  to 
the  genio-hyoglossi  muscles.  During  the  period  of  anesthetic 
unconsciousness  the  patient  must  be  watched,  and  at  the  first 
sign  of  difficult  respiration  the  tongue  is  to  be  pulled  forward. 
This  will  be  facilitated  by  passing  a  stout  silk  suture  through 
the  tongue  and  fastening  the  silk  loop  with  adhesive  plaster  to 
the  cheek  or  ear.  This  suture  may  be  removed  on  the  third  day, 
or  as  soon  as  the  patient  can  be  taught  to  draw  his  tongue  forward 
on  the  first  intimation  of  suffocation.  Course  of  the  Wound. — 
With  constant  watchfulness  on  the  part  of  the  attendant,  healing 
rapidly  ensues  until  the  wound  contracts  to  a  fistula.  This 
closes  readily  as  a  rule,  though  if  large  and  kept  open  by  the  en- 
trance of  saliva  and  particles  of  food,  a  secondary  plastic  opera- 
tion, may  be  necessary.  Swallowing  is  markedly  interfered  with. 
This  not  only  makes  feeding  difficult,  but  allows  the  saliva  to 
collect  in  the  mouth  cavity  and  "dribbling"  results.  Speech  is 
difficult  and  thick.  As  the  healing  process  proceeds,  the  severed 
ends  of  the  bone  sink  more  and  more  together.  In  case  of 
unilateral  disarticulation  the  remaming  side  encroaches  on  the 
operated  side.  If  the  chin  portion  of  the  jaw  has  been  removed, 
the  cut  surfaces  approach  each  other  almost  immediately. 
This  occurs  whenever  a  section  of  bone  is  removed  from  the 
continuity  of  the  lower  jaw  and  causes  great  disfigurement. 
To  avoid  this  it  is  advisable,  whenever  possible,  to  leave  a 
bridge  of  bone  connecting  the  two  lateral  portions.  If  this 
is  impossible,  an  attempt  to  prevent  the  disfigurement  may  be 
made  by  prosthesis.  To  be  successful  this  must  be  done  at 
the  time  of  operation  or  very  shortly  thereafter,  before  cicatriza- 
tion has  begun.  If  no  attempt  be  made  to  keep  the  lateral 
portion  of  the  jaw  in  its  proper  relations  not  only  will  great 


OPERATIONS    ON    THE    NECK  393 

disfigurement  result,  but  by  reason  of  the  loss  of  alignment  of  the 
teeth,  mastication  will  become  impossible.  In  time  changes 
will  take  place  in  the  conformation  of  the  upper  jaw  as  well. 
Prosthetic  apparatus  introduced  after  cicatrization  is  well  under 
way,  while  they  aid  somewhat,  do  not  overcome  entirely  these 
serious  defects.  The  introduction  of  pieces  of  steel  wire  between 
the  fragments  at  the  time  of  operation  has  been  done,  with 
partial  success.  It  has  been  recommended  (Nussbaum)  that  an 
accurate,  hard-rubber  model  be  made  of  the  lower  jaw  in  each 
individual  case.  This  is  provided  with  numerous  openings  to 
facilitate  irrigation  and  drainage.  On  removal  of  the  diseased 
segment,  a  corresponding  portion  of  the  cast  is  sawn  off  and 
placed  in  the  gap.  This  is  retained  in  position  by  wiring  it  to  the 
remaining  portion  of  the  jaw.  Eternal  vigilance  must  be 
exercised  to  ensure  the  successful  healing  of  the  artificial  portion. 
A  section  of  bone  from  another  portion  of  the  body  may  be 
wedged  in  the  gap.  This  latter  procedure  aided  by  prosthesia 
will  give  the  best  result.  Unless  successful  the  final  condition  of 
these  patients  will  be  one  of  deformity,  imperfect  speech  and  diffi- 
cult deglutition.     They  are  forced  to  subsist  on  soft  or  liquid  food. 


CHAPTER  XIV. 
OPERATIONS  ON  THE  NECK. 

General    Rules    following    Operations    upon    the    Neck. — The 

elevated  head  and  trunk  position  is  useful  in  lessening  oozing 
or  the  liability  to  secondary  hemorrhage.  Care  should  be 
taken  to  protect  the  dressing  from  contamination  by  vomitus 
and  expectorated  material  while  the  patient  is  still  unconscious. 
Complications  following  Operations  upon  the  Neck. — Owing 
to  the  large  number  of  important  structures  all  wounds  and 
injuries  of  the  neck  require  special  care  in  the  after-treatment. 
In  ligature  of  the  jugular  vein  venous  stasis  rarely  follows  in  the 
face  even  after  ligature  of  both  the  internal  and  external  jugular, 
the  collateral  circulation  allowing  of  the  rapid  establishment  of 
the  venous  return.  Only  occasionally  does  a  thrombosis  form 
in  the  ligated  vein  as  far  as  the  next  collateral  branch;  more 


394  OPERATIXG    ROOM    AND    THE    PATIEXT 

rarely  still  is  a  portion  of  such  a  thrombus  carried  into  the  cir- 
culation to  result  in  pulmonary  embolism.  Suppuration  of  such 
a  thrombus  with  multiple  embolism  and  pyemia  is  still  rarer. 

Temporary  venous  stasis  of  the  face  may  result  following 
operations  upon  the  neck  through  too  tight  bandaging. 

Ligature  of  the  Carotid  Artery. — Acute  anemia  of  the  brain  may 
result.  This  is  preceded  by  hregularity  of  the  pupils,  headache 
and  attacks  of  dizziness;  later  unconsciousness  develops.  Hemi- 
plegia of  the  opposite  half  of  the  body  may  occur,  aphasia  may 
result,  epileptiform  convulsions  may  result,  an  increasing  weak- 
ness of  the  mentality  may  slowly  develop.  These  are  the  results 
of  permanent  insufficient  brain  nutrition.  In  such  cases  cerebral 
softening  finallj^  becomes  complete.  Usually,  however,  in  other- 
wise healthy  individuals  collateral  chculation  is  rapidly  estab- 
lished. In  those  suffering  from  arteriosclerosis,  extensive 
thrombi  and  permanent    disturbance  of    nutrition  will    result. 

Aneurysms  and  malignant  tumors  of  the  neck  are  more  apt  to 
be  complicated  in  the  after-course. 

Injury  to  the  Thoracic  Duct. — This  is  shown  by  a  copious 
flow  of  milky  fluid  from  the  wound.  The  flow  increases  during 
digestion.  It  coagulates  spontaneously  when  exposed  to  the  air. 
If  food  is  withheld  the  fluid  becomes  clear.  Treatment  consists 
in  packing  the  wound  flrmly.  If  the  duct  has  been  injured 
within  the  chest  the  chylous  fluid  will  accumulate  in  the  pleural 
cavity.  Such  ca^es  are  frequently  fatal  through  inanition.  As 
in  other  wounds  of  lymph  channels  a  granulating  condition  of 
the  Avound  should  be  brought  about  as  ciuickly  as  possible.  If 
these  granulations  do  not  close  the  defect  in  the  duct  a  lateral 
suturing  may  be  attempted.  If  this  fails  the  duct  must  be 
ligated.  Such  a  procedure  should  not  be  too  long  delayed  in 
thoracic  injuries,  for  unless  there  happens  to  be  a  free  anastomosis 
or  a  right  as  well  as  a  left  duct  rapid  inanition  results.  If  chjdo- 
thorax  follows,  the  thorax  should  be  opened  and  the  fluid  evacu- 
ated. The  lesion  is  not  so  fatal  as  was  formerly  supposed^ 
fourteen  recoveries  in  fifteen  cases  (Allen  and  Briggs). 

Secondary  Hemorrhage.- — While  secondary  hemorrhage  is  no 
more  liable  to  occur  following  operation  upon  the  neck  than 
elsewhere,  it  is  accompanied  by  greater  danger  on  account  of  the 


OPERATIOXS    ON    THE    NECK  395 

size  of  the  vessels  likely  to  be  involved.  Suppurating  wounds  pre- 
dispose to  its  occurrence  and  should  be  carefully  watched  for  this 
complication.  Such  wounds  must  receive  special  attention  as 
regards  frequent  and  careful  redressing,  rigid  cleanliness  and 
efficient  drainage.  Keeping  the  patient  quiet  in  the  elevated 
head  and  trunk  position  is  beneficial.  Upon  the  occurrence  of 
hemorrhage  digital  pressure  over  the  bleeding  area  is  immediately 
applied  and  kept  up  until  everything  is  ready  to  ligate  the  vessel. 
Packing  and  expectant  treatment  are  only  mentioned  to  be 
condemned. 

Operative  injuries  to  the  supraclavicular  nerves  are  generally 
of  little  significance;  they  result  in  loss  of  sensation,  paresthesia, 
neuralgic  pain;  these  disappear  within  a  few  months.  Injuries 
to  the  brachial  plexus  are  of  more  importance;  motor  and  sensory 
paralysis  from  actual  section  of  part  of  the  plexus  is  rare.  More 
common  are  irritative  lesions  produced  by  pressure  and  stretch- 
ing. In  extensive  dissections  in  the  region  of  the  plexus  con- 
traction of  cicatrical  tissue  and  consequent  pressure  is  apt  to 
occur.  Prophylactic  treatment  consists  in  securing  primary 
union.  If  actual  section  in  any  part  of  the  brachial  plexus 
has  occurred  immediate  suture  should  be  done  upon  the 
discovery  of  the  symptoms.  In  pressure  from  later  contrac- 
tion of  scar  tissue  excision  of  the  scar  tissue  is  indicated.  For 
painful  conditions  the  constant  electric  current  is  useful. 

In  some  operations  on  the  neck  it  is  not  possible  to  avoid 
injury  to  the  spinal  accessory  nerve.  Section  of  this  nerve  causes 
paralysis  of  the  sterno-mastoid  muscle  and  a  malformation  of 
the  neck  may  result. 

The  recurrent  laryngeal  nerve  is  sometimes  injured  in  thyroi- 
dectomy (p.  417). 

Injury  to  the  vagus  of  one  side  produces  paralysis  of  the  vocal 
cord  on  that  side  with  consequent  disturbance  of  voice  and  respi- 
ration. Increase  in  the  pulse  rate  is  not  observed  in  man.  There 
later  may  develop  suppurative  bronchitis,  lobar  pneumonia  or 
other  lung  complications.  A  direct  relation  of  these  lesions  to 
the  section  of  the  vagus  is  not  proven.  In  addition  to  the  paral- 
ysis of  the  vocal  cord  there  are  sensory  and  motor  disturbances  of 
the  pharynx  and  esophagus;  these  interfere  with  deglutition.     A 


396  OPERATING    ROOM    AND    THE    PATIENT 

foreign-body  pneumonia  may  easily  result.  In  cases  in  which 
a  vagus  has  been  injured  the  patient  should  be  fed  by  stomach 
tube  for  seven  or  eight  days  on  account  of  the  danger  of  aspira- 
tion pneumonia. 

Injury  to  the  phrenic  nerve  is  not  common.  Section  of  the  nerve 
causes  collapse  of  a  portion  of  the  lower  lobe  of  the  lung  on  the 
injured  side  and  partial  paralysis  of  the  corresponding  half  of 
the  diaphragm.  The  five  lower  intercostals  give  some  innervation 
to  the  diaphragm.  The  accident  is  not  necessarily  fatal.  In 
the  reported  fatal  cases  following  this  injury  there  were  other 
possible  causative  factors  present. 

After  section  of  the  sympathetic  there  is  contraction  of  the  pupil 
of  the  corresponding  side,  congestion  of  the  eyeball,  flushing  of 
the  face  and  in  some  cases  headache  and  dizziness.  Division 
of  the  cervico-facial,  as  happens  occasionally  in  extensive  dis- 
sections, paralyzes  the  angle  of  the  mouth.  This  is  rarely  per- 
manent.    It  may  occasion  considerable  anxiety  to  the  patient. 

Disturbances  of  the  Respiratory  Organs. — These  frequently 
occur  after  extensive  dissections  of  the  neck,  particularly  for 
malignant  disease.  For  a  few  days  following  such  operations 
there  is  acute  catarrhal  bronchitis;  to  cough  is  painful,  and  there- 
fore expectoration  is  suppressed;  for  this  reason  in  children  and 
old  people  particularly  the  deeper  air-passages  readily  become 
affected.  The  occurrence  of  pneumonia  after  extensive  dis- 
sections of  the  lower  regions  of  the  neck  should  be  borne  in  mind 
and  prophylactic  treatment  instituted. 

Infection. — The  anatomical  structure  of  the  neck  predisposes 
to  a  very  rapid  diffusion  of  infection.  Infection  follows  the  con- 
nective-tissue planes  and  may  extend  into  the  mediastinum. 
If  infection  occurs  drainage  should  be  instituted  at  once.  In 
extensive  dissections  at  the  root  of  the  neck  where  it  is  impos- 
sible to  entirely  obliterate  a  dead  space  it  is  better  to  drain  at  the 
time  of  operation  through  a  stab  wound  just  above  the  sternal 
notch. 

Dressings  for  wounds  of  the  neck  should  include  the  head  and 
chest  as  well  as  the  neck;  if  the  ears  are  included  these  should  be 
protected  from  pressure  by  cotton. 

When  deep  infection  of  the  neck  occurs  the  overlying  parts 


OPERATIONS    ON    THE    NECK  397 

become  brawny  and  fixed,  and  examination  is  difficult.  The 
brawny  area  must  be  opened  up  and  the  nidus  of  infection 
drained.  This  may  be  done  through  a  small  incision  and  the 
pushing  of  a  slender-pointed  artery  clamp  toward  the  center  of 
the  infiltration,  and  withdrawing  the  clamp  open.  Only  a  few 
drops  of  pus  may  escape.  Tube  drainage  should  be  instituted 
and  a  copious  evaporating  dressing  applied.  Should  the  fever 
not  subside  more  liberal  incisions  must  be  made.  A  rapid 
septicemia  may  follow  unless  free  drainage  is  instituted.  Edema 
of  the  glottis  may  occur. 

Ludwig's  Angina.  Diphtheritic  and  Scarlet  Fever  Lymphadeni- 
tis.— Early  and  adequate  incision  in  these  conditions  is  necessary 
to  prevent  fatal  edema  of  the  glottis  or  septicemia.  The  actual 
amount  of  pus  found  is  very  small,  the  surrounding  infiltration 
very  great.  Fenestrated  multiple  tube  drainage  is  employed. 
If  the  temperature  does  not  fall  further  incision  is  indicated. 
Irrigation  cannot  take  the  place  of  adequate  incision  and  it  is 
folly  to  wait  in  the  hope  that  the  unopened  focus  will  escape  by 
way  of  the  existing  incision.  Copious  absorbent  alcohol- 
bichlorid  dressings  are  eii^ployed  and  frequently  changed. 

Edema  of  the  Glottis. — There  is  always  danger  of  edema  of  the 
glottis  in  any  acute  suppurative  process  in  the  neighborhood. 
If  the  cause  has  been  early  and  effectively  treated  the  beginning 
edema  may  subside  and  a  tracheotomy  be  avoided.  In  cases  in 
which  it  may  reasonably  be  expected  to  progress  a  tracheotomy 
set  should  be  kept  at  the  patient's  bedside  or  a  preventive  trache- 
otomy done.  Scarifications  are  useless  before  the  seat  of  infection 
has  been  efficiently  drained. 

Lymphadenitis  and  Lymphoma. — A  radical  cure  is  not  always 
certain;  glands  which  are  small  at  the  time  of  operation  subse- 
quently become  infected  and  require  removal.  In  only  about 
one-third  of  the  cases  is  a  permanent  cure  secured.  The  cause  of 
the  enlarged  glands  should  be  sought  out  and  treated.  In 
tuberculous  cases  in  which  some  of  the  glands  were  broken  down 
persistent  sinuses  may  follow. 

Actinomycosis. — Recurrences  are  frequent  and  require  splitting 
of  the  sinuses. 

Hematoma   of   the    sterno -mastoid    may   follow   section   and 


398  OPERATIXG    ROOM    AND    THE    PATIEXT 

suture.  If  extensive  the  incision  should  be  opened  and  the  clot 
expressed.  If  the  hematoma  is  small  and  occurs  late  it  may  be 
left  alone  and  will  in  time  be  absorbed.  Infiltration  of  the 
muscle  disappears  rapidly  under  massage. 

Tracheotomy.  Choice  of  Operation. — Under  circumstances  of 
extreme  emergency  the  trachea  may  be  opened  by  a  single 
cut,  rapid  tracheotomy  (Dunham),  without  reference  to  the 
presence  of  large  veins  or  the  thyroid  isthmus.  The  trachea 
and  larynx  are  steadied  laterally  by  the  thumb  and  finger  of  the 
left  hand,  or  a  large  tenaculum  hooked  deeply  and  firmly  into 
the  cricoid  or  cricoth}rroid  membrane.  Though  a  plexus  of  veins 
lies  on  each  side  of  the  line  of  incision,  j^et  not  infrequentl}^  a 
large  vein  or  two,  increased  in  size  by  obstructed  breathing, 
crosses  the  trachea.  The  only  normal  artery  likely  to  be  met 
with  is  the  cricothj^roid,  and  this  is  placed  so  high  (at  the  lower 
border  of  the  thyroid  cartilage)  as  to  be  practically  out  of  the  way 
in  almost  all  of  the  operations  of  choice.  An  occasional  arterial 
abnormality,  the  arteria  thyroidea  ima,  is  met  with;  it  rises  from 
the  arch  of  the  aorta  and  passes  directly  upward  in  the  middle 
line  to  the  lower  border  of  the  thyroid.  In  a  low  or  infrathyroid 
tracheotomy  the  innominate  artery  may  be  endangered.  In  young 
children  the  thymus  gland  may  be  an  obstacle.  In  spite  of 
these  latter  objections  and  of  the  fact  that  the  trachea  in  child- 
ren is  more  deeply  placed  and  smaller,  in  diphtheria  cases  in 
which  it  is  desirable  to  place  the  tube  as  far  away  as  possible  from 
the  pseudomembranous  exudation,  as  well  as  in  cases  of  ma- 
lignant disease  in  which  the  cannula  must  be  permanently  worn, 
the  low  operation  should  be  performed.  "Where  the  isthmus 
can  be  severed  between  two  ligatures,  the  tube  may  be  placed 
at  its  site.  In  an  emergency  requiring  rapid  tracheotomy,  and 
under  circumstances  which  demand  prompt  interference  on  ac- 
count of  threatened  suffocation,  the  most  superficial  portion  of 
the  tube  is  chosen  (laryngotracheotomy). 

The  Operation. — The  patient,  if  a  child,  is  wrapped  in  a  blanket 
which  is  snugly  pinned  so  as  to  confine  the  arms  at  the  lateral 
portions  of  the  body;  they  should  not  be  crossed  over  the  chest. 
He  is  placed  on  the  table  so  that  a  good  light  may  be  obtained. 
The  parts  to  be  operated  on  are  brought  into  prominence  by  a 


OPERATIONS    ON    THE    NECK  399 

hard  pillow  made  by  wrapping  a  wine  bottle  in  a  towel,  or  some 
similar  device.  The  instruments  required  are  a  scalpel,  half  a 
dozen  artery  clamps  (French's  clamps  are  the  most  convenient 
Fig.  186),  four  small  retractors  (Fig.  187)  (two  sharp  and  two 
blunt),  two  pairs  of  thumb  forceps,  a  grooved  director,  a  strong 
and  well-curved  tenaculum  for  fixing  the  trachea  (Fig.  188), 
curved  and  straight  blunt-pointed  scissors,  an  aneurism  needle, 


Fig.  186. — French's  combined  hemostatic  forceps  and  retractor. 
(Fowler's  Surgery.) 

and  curved  and  straight  needles.  Silk  and  catgut  are  also  needed 
for  suture  and  ligature  purposes.  An  assortment  of  tubes  must 
be  at  hand.  The  one  best  adapted  to  the  case  is  prepared,  with 
tapes  attached,  and  placed  conveniently  near.  The  other 
instruments  are  placed  in  the  order  in  which  they  are  to  be  used. 
A  median  incision  is  made  from  the  lower  edge  of  the  cricoid 
cartilage  downward  for  from  an  inch  and  a  half  to  two  inches, 


Fig.   187. — Pilcher's  retractors.      (Fowler's  Surgery.) 

including  the  skin  and  superficial  fascia;  the  anterior  jugular 
veins,  one  on  each  side  of  the  larynx  and  trachea,  pass  downward 
and  are  joined  by  a  transverse  trunk  just  above  the  sternum. 
The  lateral  ribbon-shaped  muscles  (the  crico-thyroid  above  and 
the  sterno-thyroid  below)  are  separated  by  the  handle  of  the 
scalpel  and  drawn  apart  by  small  blunt  retractors,  so  that  the 
deep  fascia  is  brought  into  view.     The  latter  divides  into  two 


400 


OPERATING    ROOM    AND    THE    PATIEXT 


Fig.  188.— Com- 
bined grooved  di- 
rector and  tenacu- 
lum. (Fowler's 
Surgery.) 


layers  to  inclose  the  isthmus  of  the  thyroid,  which  is  recognized 
by  its  pinkish-red  appearance,  resting  on  the  second  and  third 
rings  of  the  trachea.  The  deep  fascia  is  care- 
fully nicked  just  below  the  lower  border  of 
the  isthmus  and  divided  on  a  grooved  direc- 
tor, the  incision  baring  the  rings  of  the 
trachea  with  some  loose  connective  tissue  in 
front.  A  stout  tenaculum  is  now  inserted, 
point  upward,  at  the  lower  border  of  the 
isthmus  into  the  trachea  to  steady  the  latter 
while  it  is  being  incised.  Whenever  possible, 
a  loop  of  strong  silk  is  passed  through  each 
edge  of  the  tracheal  incision  for  purposes  of 
retraction,  or  the  incision  held  apart  by 
tenacula  and  as  large  a  tube  as  can  be  passed 
without  crowding  is  introduced. 

A'arious  tracheotomy  tubes  have  been  devised; 
the  best  is  that  known  as  the  Cohen  model 
(Fig.  189).  It  is  flattened  from  side  to  side, 
so  that  its  introduction  is  facilitated  and  the  tendency  of  the 
posterior  wall  to  bulge  forward,  as  a  conseciuence  of  wide 
separation  of  the  edges  of  the  divided  tracheal  rings,  is  lessened. 
A  pilot  trocar  aids  in  the  intro- 
duction in  emergency  cases  and 
during  the  after-treatment,  but 
if  the  loops  of  thread  above  men- 
tioned can  be  placed  in  position 
and  retained,  this,  as  well  as 
tracheal  dilators,  can  be  dispensed 
with.  The  wound  is  closed  by  in- 
terrupted sutures,  except  at  the 
point  Avhere  the  tube  emerges,  and 
dressed  with  iodoform  gauze. 

The  tube  is  secured  in  place  by 
tapes  about  the  neck  and  covered 
by    a    few  thicknesses   of    gauze 

saturated  with  sterilized  normal  salt  solution.     The  atmosphere 
of  the  room  is  kept  moist  and  at  a  temperature  of  at  least  80°  F. 


Fig.  189. — Cohen's  tracheotomy 
tubes.  1,  Outside  tube  and  ob- 
turator; 2,  obturator;  3,  inside 
tube;  a,  cross-section  of  the  tube. 
(Fowler's  Surgery.) 


OPERATIONS    ON    THE    NECK  401 

In  croup  and  diphtheria  cases  a  watchful  care  is  to  be  exercised 
to  prevent  the  tube  from  becoming  blocked  by  pieces  of  false 
membrane.  The  inner  tube  is  to  be  removed  and  cleansed  from 
time  to  time.  In  an  emergency  both  tubes  are  to  be  removed 
at  once  and  the  patency  of  the  opening  maintained  by  the  loops 
of  thread.  The  tube  should  be  dispensed  with  at  the  very 
earliest   possible  moment. 

The  Importance  of  the  After-treatment. — Tracheotomized  pa- 
tients should  be  constantly  watched  in  order  to  rectify  immedi- 
ately any  displacement  of  the  tube.  This  is  especially  important 
in  laryngeal  stenosis  from  whatever  cause.  There  should  be 
an  attendant  constantly  by  the  bedside  for  the  first  few  days, 
or  until  such  a  time  as  the  trachea  becomes  fixed  in  the  wound 
and  the  danger  of  asphyxia  from  the  displacement  of  the  tube 
is  no  longer  imminent. 

Method  of  Retaining  the  Tube  in  Position. — The  tube  is  held 
in  place  by  two  tapes,  one  end  of  each  being  attached  to  either 
side  of  the  shield  of  the  tube  through  an  aperture  made  for  the 
purpose.  To  ensure  the  tapes  lying  smoothly  on  the  neck  a 
small  slit  is  cut  in  one  end  of  each  tape,  the  slit  ends  are  passed 
through  the  aperture  at  either  side  of  the  shield  of  the  tube  and 
the  free  end  of  each  tape  is  then  passed  through  the  slit  in  the 
other  end  forming  a  slip-noose.  This  is  drawn  down  snugly. 
The  free  ends  of  the  tape  are  then  tied  together  at  the  back  of 
the  neck.  The  tapes  should  be  one  quarter  of  an  inch  broad 
and  sufficiently  long  to  allow  of  easy  tying.  Care  must  be  taken 
that  they  are  not  tied  too  tightly  or  the  return  circulation  in  the 
large  veins  of  the  neck  will  be  interfered  with;  on  the  other  hand 
if  too  loosely  tied  there  is  danger  that  an  attack  of  coughing  will 
displace  the  tube. 

Care  of  the  Wound. — The  wound  in  diphtheria  cases  is  best 
left  open;  in  other  cases  one  or  two  sutures  may  be  placed  at 
each  extremity  of  the  wound.  A  four-inch  square  of  gauze 
several  layers  thick  is  cut  from  one  side  to  just  beyond  its 
center  and  slipped  under  the  shield  to  prevent  the  latter  from 
pressing  on  the  wound  and  skin  edges.  Over  the  external 
opening  of  the  tube  is  laid,  not  fastened,  a  single  thickness  of 
gauze  moistened  for  the  first  few  days  with  a  weak  solution  of 

26 


402  OPERATING    ROOM    AND    THE    PATIENT 

turpentine  or  boracic  acid  solution.  This  is  renewed  every 
few  hours.  When  patient  is  up  and  about  a  simple  gauze 
covering  to  filter  the  air  is  sufficient. 

Course  following  Introduction  of  the  Tube. — The  introduction 
of  the  tube  always  excites  some  cough.  Mucus  slightly  tinged 
with  blood  is  expelled  through  the  tube.  This  quickly  dis- 
appears, quiet  respirations  ensue,  and  normal  color  replaces  the 
cyanosis.  It  is  not  uncommon  for  patients  who  have  been 
fighting  for  air  previous  to  the  introduction  of  the  tube  to  sink 
into  a  quiet  slumber  as  soon  as  the  free  passage  of  air  is 
established. 

Occlusion  of  the  Tube  by  Mucus. — Next  in  importance  to 
keeping  the  tube  in  place  is  the  necessity  for  keeping  its  lumen 
clear  of  mucus.  This  is  accomplished  by  removing  the  inner 
tube,  cleansing,  and  replacing  it.  The  periods  at  which  this 
should  be  done  vary  according  to  the  case.  In  the  ordinary 
case  three  times  a  day  is  sufficient.  Upon  the  recurrence 
of  dyspnea  the  inner  tube  should  be  immediately  withdrawn, 
cleansed,  and  replaced.  In  cases  uncomplicated  by  involvement 
of  the  tracheal  mucous  membrane  there  will  be  but  slight 
mucous  discharge.  In  diphtheria  cases  a  cast  of  the  entire 
tracheal  mucous  membrane  may  be  thrown  off.  Particles 
of  tenacious  mucus  easily  adhere  to  the  opening  and  inner 
surface  of  the  tube.  More  and  more  mucus  collects  and  dries 
until  the  lumen  is  so  encroached  upon  that  dyspnea  sets  in. 
By  constantly  changing  the  moist  gauze  over  the  external 
opening  of  the  tube  the  drying  of  the  mucus  in  the  tube  may  be 
materially  lessened.  In  cases  in  which  the  mucus  is  very 
tenacious  a  steam  kettle  should  be  used  to  keep  the  air  in  the 
room  moist.  An  alkaline  spray  (bicarbonate  of  soda  in  the 
strength  of  ten  grains  to  the  ounce)  may  be  used  through  the 
tube  every  two  hours  to  aid  in  loosening  the  tough  membrane 
in  diphtheria  cases.  As  fast  as  mucus  is  coughed  through  the 
tube  it  should  be  sponged  away  and  never  allowed  to  remain  in 
the  external  opening  where  it  may  be  drawn  back  into  the 
trachea  again.  In  replacing  the  inner  tube  after  cleansing, 
be  sure  that  it  is  completely  replaced  and  caught  by  the  catch 
on  the  shield,  as  otherwise  there  will  be  left  a  small  opening  at 


OPERATIONS    ON    THE    NECK  403 

the  lower  end  of  the  tube  between  the  inner  and  outer  tube.  In 
this  crevice,  mucus  will  gather  and  glue  the  two  tubes  together 
so  that  when  it  again  becomes  necessary  to  remove  the  inner  tube 
in  order  to  cleanse  it,  it  will  be  found  that  this  can  only  be  done 
by  removing  both  tubes,  so  intimately  will  they  be  glued  together. 

A  large  piece  of  membrane  may  block  the  tube  by  becoming 
lodged  against  its  inner  orifice  and  dyspnea  become  extreme. 
In  such  a  case  remove  the  inner  tube  and  if  the  membrane  is  not 
expelled,  break  it  up  by  introducing  a  soft  catheter  and  it  will 
usually  be  expelled  by  the  next  violent  cough.  Should  this 
maneuver  fail  to  give  relief,  both  tubes  should  be  removed. 

Displacement  of  the  Tube. — This  is  usually  caused  by  a  violent 
cough.  If  it  occurs  before  the  trachea  has  become  fixed  in 
the  wound,  immediate  dyspnea  results.  Occurring  later  the 
symptoms  are  not  urgent  as  the  opening  in  the  trachea  has 
become  part  of  the  external  wound  and  is  rigidly  held  open. 
The  tube  may  only  slip  forward  a  short  distance  and  yet  be 
outside  the  trachea.  Should  this  occur  shortly  after  the  opera- 
tion the  slit  in  the  trachea  will  collapse,  dyspnea  ensues  and 
death  from  asphyxia  will  be  imminent.  The  projection  of  the 
tube  forward  may  be  hardly  noticeable  externally,  especially 
in  low  tracheotomy.  The  impulse  of  the  untrained  attendant 
is  to  push  the  tube  deeper  and  tighten  the  tape  but  this  does 
not  relieve  the  symptoms  as  the  inner  end  of  the  tube  only 
pushes  the  trachea  before  it,  or  is  pushed  downward  in  the 
pre-tracheal  tissue.  This  latter  favors  infection  of  these  tissues 
if  the  patient  survives.  Should  the  case  not  die  in  a  short  time 
of  asphyxia,  emphysema  of  the  tissues  of  the  neck  and  body 
will  result.  Without  intervention  this  emphysema  will  extend 
to  all  the  superficial  tissues  of  the  body.  The  tape  fastening 
the  tube  will  cut  deeply  into  the  swollen  tissues  of  the  neck. 
Upon  replacing  the  tube  in  its  proper  position  in  the  trachea 
these  symptoms  subside.  The  emphysema  is  not  fatal  unless  it 
should  enter  the  mediastinum  and  prevent  the  expansion  of  the 
lung.     Naturally,  however,  it  favors  sepsis. 

Replacement  of  the  tube. — The  reintroduction  of  the  tube 
requires  as  much,  if  not  more  skill,  than  the  tracheotomy 
itself.     The  patient  is  placed  as  for  tracheotomy,  a  sandbag 


404  OPERATING    ROOM    AND    THE    PATIENT 

under  shoulder,  the  head  bent  backward  slightly  to  thoroughly 
expose  the  parts.  An  assistant  sitting  at  the  patient's  head 
fixes  it  by  grasping  the  temples.  A  second  assistant  holds  the 
body,  preferably  bj^  pressing  both  arms  to  the  patient's  thorax 
with  shoulders  down  by  traction  on  the  arm  and  by  a  slight 
pressure  of  his  body  upon  the  lower  extremities  prevents  the 
child's  struggling.  Remove  the  tube  completely,  retract  the 
edges  of  the  wound  with  blunt  hooks,  raise  and  steady  the  trachea 
with  a  tenacukuTL  introduced  at  the  upper  angle  of  the  wound, 
separate  the  tracheal  wound  edges  with  tenacula  or  tracheal 
retraction  forceps,  and  introduce  the  tube.  If  the  original  tube 
is  too  short  on  account  of  the  swelling  a  longer  tube  must  be 
used.  If  no  other  tube  is  at  hand  a  thick-walled  rubber  drain  or 
catheter  may  be  used  temporarily,  or  the  trachea  may  be  sewed 
to  the  skin.  Proceed  methodically  taking  care  that  wound  secre- 
tion is  not  inspirated. 

Wound  Complicatio7is. — Immediate  hemorrhage  is  due  to  errors 
in  technic  during  the  operation.  Hemorrhage  should  have  been 
controlled  before  opening  the  trachea  whenever  the  emergency 
permits.  Bleeding  from  the  tracheal  wound  or  tracheal  mucous 
membrane  is  rarely  marked.  If  the  bleeding  from  the  wound  is 
profuse  its  source  must  be  looked  for  and  checked.  If  slight, 
tamponade  of  the  wound  will  be  sufficient.  Secondary  hemor- 
rhage may  occur  on  the  third  daj^  or  later  and  is  due  to  suppu- 
ration ill  the  wound,  thrombosis  of  the  tracheal  veins,  or  injury 
to  the  thja'oid  gland,  more  rarely  to  the  erosion  of  a  large  vessel. 
In  the  latter  case  the  hemorrhage  will  not  occur  until  the  seventh 
to  the  tenth  day.  The  treatment  consists  in  immediately  con- 
trolling the  hemorrhage  by  digital  pressure  and  then  formally 
clamping  and  ligating  as  quickly  as  possible. 

Ulcers  of  the  tracheal  mucous  membrane  caused  by  pressure 
from  the  tube  will  cause  slight  repeated  hemorrhages;  at  first 
blood-stained  mucous  is  coughed  out,  later  pure  blood.  The 
blood-stained  sputum  will  first  call  attention  to  the  condition. 
This  is  caused  by  using  too  large  a  tube  or  by  faulty  position  of 
the  tube.  It  may  be  accompanied  by  edema.  The  treatment  is 
to  remove  the  tube  and  replace  it  by  one  of  different  curve  and 
size. 


OPERATIONS    ON    THE    NECK  405 

Wound  infection  rarely  occurs.  An  aseptic  tracheotomy 
wound  cannot  be  obtained  but  usually  infection  is  only  of  a 
mild  character.  More  rarely  the  wound  edges  become  in- 
durated, a  grayish- white  slough  forms  on  the  wound  surface  but 
as  drainage  is  very  free  the  inflammation  does  not  tend  to  pro- 
gress and  when  granulation  progresses  the  infection  rapidly 
clears  up.  If  there  is  any  tendency  to  spread  incisions  should  be 
made,  so  placed  as  to  prevent  pocketing  and  extension  toward 
the  mediastinum. 

Wound  diphtheria  is  now  rare,  antitoxin  controlling  the  spread 
of  the  inflammation.  The  wound  surfaces  are  covered  by 
fibrous  exudate  and  this  may  extend  into  the  tissues;  the  margins 
of  the  wound  are  ulcerated  and  the  tracheal  cartilages  exposed 
in  the  incision  become  necrotic.  There  is  a  tendency  to  extend 
downward  to  the  mediastinum.  Usually  such  a  case  is  fatal. 
Occasionally  the  wound  will  clean  up  and  healing  follow  but 
cicatricial  stenosis  is  apt  to  follow  the  tracheal  ulceration.  The 
case  may  be  further  complicated  by  a  streptococcus  infection  of 
the  submaxillary  and  submental  glands  for  which  free  incisions 
with  drainage  are  necessary. 

Removal  of  the  Cannula. — As  soon  as  normal  breathing  can  be 
established  the  tube  is  removed,  usually  on  the  fifth  to  the  tenth 
day.  The  tube  may  be  removed  earlier  in  many  cases,  especially 
in  operations  for  foreign  body.  Dyspnea  usually  occurs  to  a, 
slight  extent;  if  severe,  the  tube  should  be  replaced  and  an 
attempt  at  removal  made  a  few  days  later.  Some  cases  are 
compelled  to  wear  the  tube  for  months  owing  to  dyspnea  follow- 
ing attempts  to  remove  it.  In  such  cases  a  fenestrated  cannula 
is  useful.  Air  escapes  partly  through  the  cannula  and  partly 
through  the  convex  opening  into  the  larynx.  This  accustoms 
the  patient  to  breathe  through  the  larynx  and  usually  per- 
mits of  removal  of  the  tube  in  a  few  days.  If  respiration  is  free 
it  may  be  permanently  left  out.  Children  and  nervous  people 
become  alarmed  at  removal  of  the  tube.  In  diphtheria  cases  the 
tube  is  removed  after  the  membrane  disappears.  Edema  may 
follow  the  removal  of  the  tube  in  the  first  few  hours.  This 
complication  should  be  watched  for  and  on  its  occurrence  the 
tube  is  reinserted.     At  first,  in  diphtheria  cases  following  the 


406  OPERATING    ROOM    AND    THE    PATIENT 

removal  of  the  tracheotomj^  tube  the  voice  is  harsh,  husky  and 
stridulent;  there  is  no  dyspnea  during  quiet  breathing.  In 
some  cases,  however,  the  dyspnea  returns  repeatedly  for  from- 
twenty-four  to  forty-eight  hours  and  follows  coughing;  this  is 
due  to  some  inflammatory  swelling  of  the  larynx  even  after  the 
diphtheritic  membrane  has  disappeared.  These  cases  should  be 
watched  carefully  for  forty-eight  hours  following  removal  of  the 
tube,  and  the  tube  should  be  replaced  if  urgent  symptoms  arise. 
A  smaller  tube  should  always  be  at  hand  as  the  opening  rapidly 
closes. 

Stenosis  of  the  trachea  sometimes  occurs  due  to  extensive  ulcera- 
tion. An  attempt  at  dilatation  should  be  made  but  it  is  usually 
necessary  to  continue  to  use  the  tube. 

Granulomata  occasionally  form  on  the  edge  of  the  tracheal 
wound,  more  rarely  on  the  tracheal  wall.  Long-continued 
pressure  from  the  tube  seems  to  favor  their  occurrence.  They 
impede  respiration  by  narrowing  the  lumen  of  the  trachea.  The 
interference  with  respiration  may  occur  late,  after  the  wound 
has  healed,  in  which  event  bronchoscopy  will  determine  the  cause 
of  the  obstruction.  Occurring  early  the  granulomata  may  par- 
tially occlude  the  tube  lumen.  Treatment  is  pressure  bj^  a 
specially  constructed  tube  (Dupuis)  or  removal  with  the  curette. 
Some  cases  must  continue  to  wear  the  tube. 

Operations  on  the  Larynx. — Endo-laryngeal  operations  are 
always  followed  by  more  or  less  temporary  inflammatory  reaction 
causing  hoarseness  or  aphonia;  the  duration  and  severity  of 
which  depend  upon  the  amount  of  injury  to  the  vocal  cords  the 
result  either  of  the  operation  or  of  the  disease.  This  inflammatory 
swelling  of  the  mucous  membrane  is  marked  after  extensive 
cauterization  and  may  progress  so  rapidly  as  to  threaten  suffoca- 
tion and  demand  tracheotomy. 

Dilatation  Treatment. — As  the  after-treatment  is  apt  to  be 
prolonged  the  general  practitioner  should  familiarize  himself 
with  the  technic  of  dilatation.  This  is  necessitated  in  many 
cases  to  prevent  cicatricial  contraction  and  patients  must  be 
warned  of  the  necessity  of  such  treatment.  The  passage  of 
hard-rubber  bougies,  Schroetter's  bougies,  must  be  done  every 
second  day  for  months  in  some  cases.     The  throat  is  cocainized 


OPERATIONS    ON    THE    NECK  407 

or  the  first  few  times  and  the  confidence  of  the  patient  secured. 
An  instrument  of  a  suitable  size  is  lubricated  and  passed  in  the 
same  manner  as  an  intubation  tube.  After  a  few  times  this  can 
be  done  without  cocain.  It  is  allowed  to  remain  in  place  for  a 
few  minutes  and  then  withdrawn  and  the  next  larger  size  intro- 
duced. This  is  repeated  every  few  days  until  full  dilatation  is 
secured.  There  will  be  at  first  some  swelling  of  the  mucous 
membrane.  This  should  be  allowed  to  subside  before  proceeding 
with  the  dilatation.  Do  not  dilate  enough  to  cause  much 
reaction  on  account  of  the  danger  of  edema.  After  full  dilatation 
has  been  secured  the  bougies  are  passed  at  longer  and  longer 
intervals  until  the  tendency  to  contraction  has  been  completely 
overcome.  Some  cases  will  not  respond  to  treatment  and  these 
must  be  subjected  to  operative  interference.  The  cicatricial 
tissue  is  incised  with  the  knife  or  galvanocautery  and  dilatation 
continued.  Two  or  more  extensive  operations  may  be  necessary. 
In  cases  in  which  portions  of  the  laryngeal  cartilages  have  been 
destroyed  the  whole  cartilaginous  frame-work  may  collapse. 
This  necessitates  the  continued  wearing  of  a  tracheal  cannula. 
Such  cases  may  follow  suppurative  perichondritis,  syphilitic  or 
tuberculous  inflammation,  and  in  fractures  which  have  been 
united  with  deformity. 

Laryngotomy. — A  preliminary  tracheotomy  is  done  either  at 
the  time  of  the  operation  or  several  days  previously  if  possible. 
Following  the  completion  of  the  laryngeal  operation  the  cavity 
of  the  larynx  is  packed  with  gauze.  The  thyroid  cartilage  is 
sutured  and  the  end  of  the  gauze  packing  is  led  out  of  the  inferior 
angle  of  the  wound  or  in  case  a  high  tracheotomy  has  been  done 
alongside  of  the  tracheal  tube.  This  packing  ensures  the  arrest 
of  the  hemorrhage  and  prevents  the  entrance  of  food  which  might 
occur  during  the  first  few  days.  It  also  prevents  the  growing 
together  of  the  anterior  portion  of  the  vocal  cords.  If  it  is 
thought  wise  to  allow  of  late  inspection  of  the  interior  of  the 
larynx  the  gauze  strip  may  be  brought  out  between  the  two 
halves  of  the  thyroid  cartilage.  In  such  cases  a  secondary 
suture  of  this  cartilage  is  done  upon  the  removal  of  the  packing 
at  the  end  of  twenty-four  or  forty-eight  hours. 

All  packing  is  removed  in  from  five  to  ten  days,  but  the  tra- 


408  OPERATING    ROOM    AND    THE    PATIENT 

cheotomy  tube  must  not  be  removed  at  this  time  because  of 
the  swelling  of  the  mucous  membrane  which  follows  the  removal 
of  the  packing.  This  swelling  disappears  spontaneously  in  a 
few  days.  As  soon  as  normal  breathing  is  assured  the  trache- 
otomy tube  may  be  removed.  The  cure  is  not  yet  complete. 
Catarrhal  conditions  of  the  mucous  membrane,  proliferating 
papillomata  and  more  particularly  the  tendency  to  cicatricial 
contraction  demand  extended  endolaryngeal  treatment. 

Laryngeal  stenosis  ma}^  be  caused  by  the  growing  together  of 
the  anterior  portion  of  the  vocal  cord,  to  an  approximation  of 
the  arytenoid  cartilages,  or  to  a  lateral  or  circular  swelling  of  the 
mucous  membrane.  In  the  latter  case  not  only  is  the  relation 
of  the  vocal  cords  interfered  with  but  the  lumen  of  the  larynx  is 
lessened  and  breathing  made  difhcult.  Suffocation  may  even 
ensue. 

Laryngectomy. — Total  extirpation  of  the  larynx  has  a  high 
mortality.  The  percentage  of  cases  which  are  free  from  a  recur- 
rence of  carcinoma  at  the  end  of  three  years  is  extremely  small. 
Many  of  the  cases  die  of  septic  pneumonia  caused  by  aspiration 
of  secretion  and  of  particles  of  food  or  by  an  infection  which 
travels  rapidly  along  the  trachea  into  the  mediastinum.  This 
infection  is  due  to  the  close  proximity  of  the  mouth. 

Complete  occlusion  of  the  wound  is  impossible.  The  most 
that  can  be  accomplished  is  to  suture  as  completely  as  possible 
the  pharyngeal  membrane  to  the  thyrohyoid  membrane  below 
the  hyoid  bone.  In  case  of  high  tracheotomy  the  trachea  is 
sewn  to  the  skin  edges  at  the  lower  angle  of  the  wound.  This 
tracheotomy  should  have  been  done  preliminarily,  if  possible 
at  least  one  week  before.  If  the  trachea  is  cut  directly  across 
and  sewn  into  the  wound  no  tracheotomy  tube  is  necessary. 
The  large  wound  resulting  from  the  extirpation  of  the  larynx  is 
packed  with  gauze  or  closed  with  strip  drainage  if  good  approxi- 
mation has  been  secured. 

Nutrition  is  carried  on  through  a  stomach  tube  which  emerges 
at  the  upper  angle  of  the  wound,  or  feeding  can  be  done  per 
rectum  for  three  or  four  days  and  then  by  mouth.  The  stomach 
tube  is  left  in  position  for  two  or  three  days.  After  this  the  tube 
may  be  withdrawn  and  thereafter  introduced  through  the  mouth 


OPERATIONS    ON    THE    NECK  409 

as  occasion  requires.  In  eight  to  ten  days  the  patient  will  be 
able  to  take  small  quantities  of  fluid  food  without  the  aid  of  the 
tube  as  by  this  time  the  process  of  granulation  is  well  under  way. 
It  is  highly  important  that  the  mouth  and  teeth  be  keyt  scrupu- 
lously clean.  The  flow  of  saliva  is  usually  so  great  as  to  soak  the 
packing  in  a  short  time.  This  should  be  changed  as  frequently 
as  soiled,  usually  three  or  four  times  a  day  at  first.  Minute  doses 
of  morphin  and  atropin  will  help  greatly  in  controlling  the  excess- 
ive secretion  of  saliva.  On  the  tenth  day  many  patients  are 
able  to  take  soft  food.  If  the  epiglottis  has  been  removed  fluid 
will  flow  readily  through  the  wound  cavity  soaking  the  packing. 
This  necessitates  frequent  change  of  dressing.  As  time  passes 
the  tendency  of  saliva  and  fluid  to  flow  through  the  wound 
cavity  becomes  markedly  less.  If  it  is  found  that  the  patient 
cannot  swallow  satisfactorily  the  stomach  tube  must  be  employed. 
If  a  low  tracheotomy  has  been  done  the  tube  may  be  removed 
and  the  wound  allowed  to  heal,  a  large  tube  being  introduced 
through  the  laryngectomy  wound.  The  wound  cavity  closes 
rapidly  and  in  two  or  three  weeks  packing  may  be  discontinued 
and  an  artificial  larynx  (Fig.  191)  inserted.  This  should  be 
done  before  final  contraction  of  the  parts  above  the  stump  of  the 
trachea  occurs.  The  speech  thus  obtained  is  such  as  can  be  easily 
understood,  though  it  is  absolutely  monotone.  The  vocalizing 
portion  of  the  apparatus  obstructs  the  breathing  as  soon  as 
mucus  collects  upon  it,  and  patients  must  be  taught  to  remove 
it  for  purposes  of  cleansing.  Without  it,  conversation  can  be 
carried  on  in  a  whisper,  the  consonant  sounds  being  formed 
by  the  closing  of  the  external  opening  and  the  forcing  of  the  air 
through  the  pharyngeal,  oral,  and  nasal  cavities. 

When  eating,  the  patient  replaces  the  vocalizing  apparatus  by 
an  obturator  which  closes  the  upper  or  chimney  portion  of  the 
artificial  larynx  (P.  Bruns)  and  prevents  food  from  being  forced 
into  the  tube.  He  soon  learns  to  substitute  the  base  of  the  tongue 
for  the  removed  epiglottis  and  dispenses  with  the  obturator 
entirely. 

Partial  laryngectomy  is  treated  along  the  same  lines  as  the 
complete  operation.  Whether  the  tracheotomy  tube  can  be  left 
out  entirely  and  the  tracheal  wound  allowed  to  close  must  be 


410 


OPERATING    ROOM    AXD    THE    PATIEXT 


determined  in  the  individual  case.  In  extirpation  of  one-half 
of  the  larynx  the  voice  may  become  almost  normal  owing  to  the 
tendency  of  the  remaining  vocal  cord  to  go  toward  the  median 
line  and  meet  the  cicatrical  tissue  following  the  extirpation. 

Intubation  of  the  Larynx  (O'Dwyer). — This  operation  has 
largely  replaced  tracheotomy  in  cases  of  diphtheria.  It  is  also 
employed  in  stenosis  of  the  larynx  from  causes  other  than  malig- 
nant disease.     As  in  the  case  of  tracheotomy,  it  should  be  per- 


Fig.  190. — O'DwA^er's  intubation  instruments.  A.  Tube  vrith  obturator; 
B.  tube;  C.  obturator;  D.  metal  gauge;  E,  mouth-gag;  F,  introducer;  G, 
extractor;  H.  silk  cord.      (Fo^vler"s  Surgery.) 


formed  early  in  order  that  the  greatest  benefit  may  be  derived 
from  its  use.  It  has  the  disadvantage  of  requiring  special  instru- 
ments for  its  performance,  whereas  in  tracheotomy  the  urgently 
demanded  relief  can  be  obtained  by  means  of  instruments  usually 
at  hand.  This  disadvantage  is  offset,  however,  by  the  fact  that 
it  entails  neither  loss  of  blood  nor  shock,  and  can  be  speedily 
performed. 


OPERATIONS    ON    THE    NECK 


411 


The  instruments  as  ordinarily  supplied  are  (1)  a  set  of  tubes 
with  obturators,  adapted  to  the  ages  between  one  and  twelve 
years;  (2)  a  metal  gauge  to  aid  in  the  selection  of  the  proper  tube; 
(3)  a  mouth-gag;  (4)  a  tube  introducer;  (5)  a  tube  extractor 
(Fig.  190). 

Operation. — The  child  is  held  upright  on  the  lap  of  an  attendant, 
with  its  head  resting  on  the  latter's  left  shoulder,  so  that  the  body, 
head,  and  neck  are  in  a  straight  line.  The  arms  are  held  securely 
against  the  patient's  body.  The  mouth-gag  is  inserted  in  the 
left  angle  of  the  mouth  as  far  back  as  possible  between  the  teeth, 
and  the  latter  forced  apart  as  far  as  possible.     The  proper  sized 


Fig.  191. — Park's  modification  of  Gussenbauer's  artificial  larynx. 
(Fowler's  Surgery.) 


tube  is  attached  to  the  introducer  by  its  obturator,  a  piece  of 
thread  attached  to  the  tube  by  passing  it  through  a  hole  provided 
for  the  purpose,  and  the  thread  wound  around  the  little  finger 
of  the  right  hand  of  the  operator.  This  thread  is  to  facilitate 
the  immediate  withdrawal  of  the  tube  should  it  become  improp- 
erly lodged.  The  introducer  is  grasped  in  the  right  hand  while 
the  tip  of  the  left  index-finger  is  passed  to  the  epiglottis,  identi- 
fying it.  The  latter  is  raised  so  as  to  uncover  the  glottic  opening 
and  the  tube  is  passed,  guarded  by  the  index-finger.  As  the 
tube  glides  over  the  now  vertically  placed  epiglottis  and  enters 


412  OPERATING    ROOM    AND    THE    PATIENT 

the  glottis,  the  guiding  index-finger  is  shifted  posteriorly  toward 
the  pharyngeal  wall,  where  it  prevents  the  tube  from  slipping 
into  the  esophagus.  The  proper  position  of  the  tube  being 
assured,  it  is  at  once  driven  home  and  at  the  same  time  released 
from  its  obturator  and  the  introducer  by  pushing  forward  the 
slide  on  the  latter  with  the  thumb  of  the  right  hand.  The  intro- 
ducer with  the  attached  obturator  is  now  withdrawn.  The  left 
index-finger  then  identifies  the  tube  in  position,  and,  if  not 
placed  well  down  in  the  glottic  opening,  it  is  pressed  home  by  the 
same  finger.  The  gag  is  then  removed.  If  the  breathing  is  re- 
lieved, the  gag  is  again  introduced  and  the  tube  steadied  with 
the  finger  as  before,  while  the  thread  is  withdrawn.  In  case  the 
tube  is  expelled  by  the  subsequent  coughing  efforts,  a  larger  one 
should  be  introduced. 

The  removal  of  the  tube,  which  is  usually  safe  after  from  three 
to  nine  days,  is  effected  by  a  maneuver  similar  to  that  by  which 
it  was  introduced.  The  child  is  held  in  the  same  manner,  the 
gag  introduced,  the  top  of  the  tube  identified  by  the  index- 
finger,  and  the  extractor  introduced.  The  blades  of  the  latter 
are  released  by  a  device  on  the  shank  worked  by  the  thumb  of 
.the  hand  which  grasps  the  instrument  as  the  point  of  the  latter 
passes  into  the  lumen  of  the  tube.  The  spread-out  blades  of 
the  extractor  engage  the  tube  and  the  latter  is  withdrawn. 

The  following  precautions  must  be  observed:  (1)  The  operator 
should  become  thoroughly  familiar  with  the  mechanism  of  the 
instruments,  and,  if  possible,  practise  the  operation  upon  the 
cadaver;  (2)  the  finger  should  not  be  held  too  long  over  the 
glottis  lest  suffocation  take  place. 

The  dangers  of  the  operation  are  the  following:  (1)  Membrane 
may  be  pushed  ahead  of  the  tube  and  produce  obstruction. 
This  will  necessitate  withdrawing  the  tube  immediately  and 
waiting  until  the  loosened  membrane  has  been  expelled  before 
reintroducing  it,  (2)  Failure  to  remove  the  thread  may  lead 
to  the  swallowing  of  the  latter,  followed  by  the  tube  itseff. 
Should  this  occur,  another  tube  must  be  introduced  at  once. 
The  swallowed  tube  will  be  expelled  with  the  bowel  movements. 
Following  intubation  if  a  string  is  left  attached  to  tube,  the 
child's  hands  are  fastened  so  that  the  tube  cannot  be  withdrawn. 


OPERATIONS    ON    THE    NECK  413 

The  child  should  be  watched  for  an  hour  or  so  to  see  that  the 
tube  is  not  coughed  up.  The  tube  should  be  changed  on  the 
third  or  fourth  day  but  is  not  to  be  replaced  oftener  than  neces- 
sary. Some  recommend  leaving  it  in  place  a  week  before  chang- 
ing. The  main  problem  is  the  feeding.  O'Dwyer  recommended 
placing  the  patient  in  a  horizontal  position  with  head  hanging 
over  the  knee,  or  edge  of  table,  and  feeding  fluids  or  semi-solids 
with  a  spoon.  However,  many  now  feed  their  patients  in  the 
upright  position  from  the  beginning,  and  although  at  first  this 
causes  coughing,  in  a  few  hours  the  children  become  accustomed 
to  the  tube  and  swallow  without  any  difficulty  whatever. 

Feeding  through  a  catheter  passed  through  the  nose  or  mouth 
into  the  esophagus  is  now  seldom  practised. 

Pharyngotomy. — The  same  rules  apply  as  in  operations  upon 
the  mouth.  Preliminary  tracheotomy  may  have  been  per- 
formed. In  case  of  extirpation  of  tumors  of  the  pharynx  or 
epiglottis  the  wound  is  closed  as  much  as  possible  and  packed; 
if  large  defects  of  the  mucous  membrane  are  present  the  tampon 
is  left  undisturbed  for  from  five  to  seven  days  unless  soiled. 
The  external  dressing-  is  changed  frequently.  If  infection 
occurs  the  packing  is  removed  and  the  wound  frequently  irrigated 
with  a  mild  alkaline  solution.  Resulting  fistulae  are  closed  by 
secondary  operations.  The  patient  is  nourished  by  tube  until 
he  is  able  to  swallow,  usually  for  four  or  five  days.  After  five 
days  granulations  have  sprung  up  in  the  wound  and  infection 
of  the  para-esophageal  tissues  is  no  longer  feared.  The  mouth 
is  kept  scrupulously  clean. 

Operations  upon  the  Esophagus. — The  conditions  calling  for 
operation  have  usually  resulted  in  emaciation  and  extreme 
weakness  before  operation  is  resorted  to.  Rectal  feeding  and 
the  administration  of  saline  by  rectum  or  by  hypodermoclysis 
is  therefore  a  requisite  to  success. 

Esophagotomy  (for  foreign  bodies). — The  patient  is  fed 
twice  daily  for  six  days  using  a  small  stomach  tube,  directed 
as  far  as  possible  away  from  the  line  of  suture.  On  the  second 
day  small  sips  of  hot  water  may  be  taken  at  long  intervals. 
On  the  third  day  the  intervals  are  shorter  and  on  the  fourth  day 
if  there  has  been  no  leakage  small  sips  of  other  sterile  fluids  are 


414  OPERATING    ROOM    AND    THE    PATIENT 

alloT\'ed.  Large  swallows  must  not  be  taken  before  the  tenth 
day.  Thereafter  solid  feeding  is  gradually  instituted.  Wound 
treatment  differs  whether  the  external  wound  is  sutured  or  not. 
If  unsutured  the  tamponade  is  left  undisturbed  for  four  days 
when  if  there  has  been  no  leakage  or  infection  the  wound  is 
sutured  or  strapped.  If  sutui'ed  except  for  the  emergence  of  a 
small  drain  this  is  removed  at  the  end  of  twenty-four  hoiu's. 
External  dressings  are  changed  as  frequently  as  soiled  by 
vomit  us  or  discharge.  Esophageal  fistula  if  persistent  requires 
secondary  plastic  operation.  The  occurrence  of  fistula  calls 
for  cleaning  of  the  wound  by  frequent  irrigation,  frequent  change 
of  dressing  and  tube  feeding. 

Excision  of  Esophageal  Diverticula. — The  treatment  is  similar 
to  esophagotomy  for  foreign  bod^'. 

Esophagectomy. — The  principal  dangers  are  sepsis  occurring 
in  the  peri-esophageal  tissues  and  secondary  hemorrhage.  The 
prognosis  is  serious,  especially  so  if  infection  is  already  present. 
Infection  may  travel  to  the  mediastinum  or  pleura  or  general 
sepsis  may  occur.  The  wound  in  the  esophagus  is  completely 
closed  if  there  is  no  nearby  infection.  The  entire  wound  may  be 
closed;  if  infection  is  present,  however,  the  outer  layers  of  the 
wound  are  not  closed  but  the  wound  is  tamponed  down  to  the 
line  of  sutures  in  the  esophagus.  Such  a  wound  is  closed  by 
secondary  suturing  as  soon  as  infection  has  subsided.  Feeding 
is  conducted  as  following  esophagotomy.  Solid  food  should  not 
be  allowed  for  fourteen  days,  or  until  the  healing  of  the  esopha- 
geal wound  is  complete.  After  esophagectomy  for  carcinoma 
accurate  suturing  is  impossible;  the  lower  end  of  the  esophagus 
may  be  either  partially  or  completely  sutui'ed  in  the  wound  as 
near  as  possible  to  the  upper  end.  A  stomach  tube  is  introduced 
through  the  wound  and  the  wound  tamponed.  The  care  of  the 
wound  is  as  outlined  in  fistula  following  esophagotomy.  A 
secondary   operation   maj'   be   necessary   to   close   the   fistula. 

Stricture  caused  by  cicatricial  contraction  of  the  esophageal 
wound  is  rare.  Should  it  occur  it  must  be  treated  by  the  passage 
of  bougies,  Secondory  hemorrhage  may  result  from  the  erosion 
of  a  vessel  by  sepsis;  the  hemorrhage  is  usually  from  the  in- 
ferior thyroid  artery.     Cases  complicated  by  septic  processes 


OPERATIONS    ON    THE    NECK  415 

must  be  watched  for  the  occurrence  of  hemorrhage  and  the 
attendant  should  be  instructed  to  immediately  open  the  wound 
and  apply  digital  pressure;  subsequently  the  inferior  thyroid 
artery  is  ligated. 

External  or  internal  esophagotomy  done  for  stricture  must  be 
followed  by  months  of  methodical  dilatation  by  bougies.  In 
case  of  internal  esophagotomy  soft  bougies  only  should  be  used 
following  the  operation  as  there  is  some  danger  of  perforation  of 
the  esophagus. 

Operations  Upon  the  Thyroid  Gland.  The  Primary  Dressing. — 
The  primary  dressing  should  be  applied  as  for  all  operations  on 
the  neck  requiring  extensive  dissection.  In  addition  a  loosely 
rolled  compress,  four  inches  in  length  by  one  in  thickness,  should 
be  placed  to  either  side  of  the  trachea  on  the  skin,  to  exert  slight 
lateral  pressure.  In  case  of  scabbard  trachea  the  retaining 
bandage  should  be  reinforced  by  a  sufficient  number  of  turns  of  a 
plaster-of -Paris  or  starch  bandage  to  ensure  the  retention  of  the 
neck  in  a  straight  position,  otherwise  the  turning  of  the  head 
might  interfere  seriously  with  respiration.  The  fixation  bandage 
should  be  so  placed  as  to  allow  of  ready  access  to  the  wound. 
In  exophthalmic  cases  the  dressing  should  consist  of  an  abun- 
dance of  fluffed-out  gauze  loosely  applied  and  loosely  bandaged 
in  place  to  provide  ready  absorption  of  the  discharge. 

General  Rules. — The  patient  is  placed  in  bed  in  the  elevated 
head  and  trunk  position  to  lessen  the  amount  of  oozing  and  the 
possibility  of  secondary  hemorrhage.  The  degree  of  elevation 
will  depend  upon  the  amount  of  shock.  Murphy  proctoclysis 
is  given  in  all  cases.  It  is  particularly  indicated  in  cases  which 
have  lost  considerable  blood  and  in  exophthalmic  cases.  In 
exophthalmic  cases  it  is  imperative  that  the  tissues  get  water 
to  combat  the  effect  of  the  hyperthyroidism  set  up  by  the 
operation.  In  these  cases  it  is  well  to  give  a  hypodermoclysis  of 
500  to  750  CO.  immediately  after  the  operation.  In  case  Murphy 
proctoclysis  is  not  retained  on  account  of  intestinal  relaxation, 
repeated  hypodermoclysis  should  be  used  (250  to  500  c.c.  every 
..three  hours).  All  cases  are  given  fluids  by  mouth  as  soon  as 
anesthetic  vomiting  has  ceased  and  a  return  made  to  normal  diet 
as  quickly  as  the  stomach  will  tolerate  it.     As  soon  as  the  patient 


416  OPERATING    ROOM    AXD    THE    PATIENT 

is  strong  enough,  usually  at  the  end  of  twenty-four  hours,  the 
head  of  the  bed  is  lowered  and  the  patient  given  a  back  rest.  At 
the  end  of  the  second  twenty-four  hours  the  patient  is  allowed 
out  of  bed  in  a  chah  and  at  the  end  of  the  third  twenty-four 
hours  may  walk  about  if  so  inclined.  In  exophthalmic  cases 
the  course  is  not  so  rapid.  There  is  usually  some  rise  in 
temperature  for  the  first  three  days  and  in  the  bad  cases  some 
acceleration  of  pulse.  The  patient  also  complains  of  head- 
ache, is  restless,  and  the  sleep  is  interfered  with.  Drugs  have 
little  if  any  influence  unless  the  cause  is  neurotic  when 
morphia  will  aid  iiji  controlling  the  restlessness.  Usually  the 
cause  is  not  free  enough  drainage  or  absorption  of  thj'roid 
secretion  in  spite  of  free  drainage.  The  treatment  is  first  to 
see  that  free  drainage  exists  and  in  addition  to  force  the  ingestion 
of  water.  The  Murphy  proctoclysis  is  given  as  fast  as  it  can 
be  absorbed  and  if  the  symptoms  persist  hypodermoclysis  is 
added,  750  to  1000  c.c.  being  given  at  first  and  250  to  500  c.c. 
at  four  hour  intervals.  In  exophthalmic  cases  also  all  sources 
of  irritation  should  be  avoided.  If  symptoms  of  hyperthj^roidism 
develop  the  patient  should  be  placed  in  a  separate  quiet  room 
with  special  attendants.  In  these  cases  the  entire  problem 
resolves  itself  into  free  drainage  and  dilution  of  the  toxins. 

Care  of  the  Wound. — There  is  a  rise  of  temperature  for  the  first 
few  days.  This  is  due  to  traumatism  to  the  remaining  portion 
of  the  gland  incidental  to  the  operation,  and  absorption  of  wound 
secretion.  It  need  occasion  no  alarm  in  any  save  the  exoph- 
thalmic cases.  In  other  than  exophthalmic  cases  packing  used 
to  control  oozing  or  drains  are  removed  at  the  end  of  forty-eight 
hours  and  a  small  drainage  strip  introduced.  This  is  renewed 
every  forty-eight  hours  as  long  as  drainage  continues.  The 
character  of  the  drainage  will  be  straw-colored  serum,  becoming 
somewhat  gelatinous  as  the  amount  decreases.  Sutm-es  are 
removed  on  the  fifth  dory.  In  exophthalmic  cases  the  dressing, 
except  the  drains,  should  be  removed  as  frequently  as  soiled  and 
dry  fluffed  out  gauze  loosely  applied.  It  is  important  that  the 
gauze  quickly  absorbs  the  secretion  and  thus  aids  the  drains.. 
The  drains  themselves  (glass  spools  with  gauze  and  green  silk 
protective  strip)  are  removed  on  the  fourth  day  or  as  soon  there- 


OPERATIONS    ON    THE    NECK  417 

after  as  the  lessening  of  the  amount  of  drainage  permits.  As 
long  as  they  drain  they  are  not  disturbed.  Upon  their  removal 
green  silk  protective  strips  are  substituted.  These  are  renewed 
every  forty-eight  hours  until  all  drainage  ceases.  In  removing 
the  original  drain,  the  glass  spool  is  first  removed  and  on  the 
following  day  the  gauze  and  green  silk  protective  drain.  If  any 
retention  of  secretion  occurs  the  drain  is  to  be  immediately 
removed  and  a  tube  drain  inserted.  If  in  spite  of  this  symptoms 
of  hyperthyroidism  persist  the  wound  is  to  be  opened  sufficiently 
to  ensure  free  drainage. 

Secondary  Hemorrhage. — This  should  be  a  rare  complication  if 
the  operation  has  been  properly  planned,  i.e.,  if  the  thyroid 
vessels  have  been  ligated  as  the  first  step  in  the  operation  and  if 
all  minute  bleeding  points  have  been  secured  by  ligature  or 
circumsuture.  Its  occurrence  necessitates  tamponade  of  the 
wound  for  forty-eight  hours.  The  tamponade  should  be  carefully 
removed  and  renewed  to  avoid  recurrence  of  the  bleeding. 

Disturbances  of  Respiration. — These  may  be  due  to  tracheitis 
from  pulling  upon  the  trachea  in  the  course  of  the  operation;  to 
edema  of  the  trachea  from  sudden  removal  of  the  pressure  in 
scabbard  trachea;  to  collapse  of  the  trachea  following  removal  of 
pressure  in  scabbard  trachea;  to  occlusion  of  the  trachea  from  sud- 
den turning  of  the  neck  in  scabbard  trachea;  to  injury  to  the 
recurrent  laryngeal  nerve  causing  paralysis  of  the  corresponding 
vocal  cord  resulting  in  aphonia,  weakened  voice,  or  foreign  body 
pneumonia;  bilateral  injury  to  the  recurrent  laryngeal  resulting  in 
asphyxia.  These  complications  are  almost  always  preventable; 
gentleness  in  manipulation,  maintenance  of  the  head  in  the  posi- 
tion in  which  breathing  is  easiest  in  scabbard  trachea,  leaving 
the  posterior  portion  of  the  capsule  intact  to  avoid  injury  to  the 
recurrent  laryngeal.  In  regard  to  laryngeal  paralysis  the  nerve 
may  have  been  pressed  upon  by  the  enlarged  thyroid  and  hoarse- 
ness and  possibly  aphonia  been  present  before  the  operation. 
If  the  pressure  has  not  been  too  long  continued  the  symptoms 
will  gradually  disappear  following  relief  of  the  pressure.  Paral- 
ysis and  collapse  of  the  corresponding  vocal  cord  will  follow, 
injury  to  the  nerve,  while  if  both  nerves  are  injured  bilateral 
paralysis  will  result  and  death  from  asphyxia  follow  unless  the 

27 


418  OPERATING    ROOM    AND    THE    PATIENT 

condition  is  promptly  recognized  and  traclieotomy  performed. 
The  injury  to  the  nerve  may  be  by  section,  clamp,  ligature  or 
traction  in  dislocating  the  enlarged  lower  lobe. 

If  due  to  clamp,  ligature  or  traction  the  resulting  hoarse- 
ness will  gradually  disappear  as  the  nerve  resumes  its  function. 
Months  may  elapse  before  this  occurs.  Even  if  the  nerve  has 
been  completely  sectioned  with  resulting  weak  and  hoarse  voice 
the  condition  will  improve  very  materially  for  in  time  the 
opposite  vocal  cord  encroaches  on  the  paralyzed  cord  and  so 
lessens  the  gap  between  the  two.  Suture  of  the  cut  nerve  has 
been  performed  with  resultant  restoration  of  function.  Care  in 
swallowing  must  be  exercised  as  a  foreign-body  pneumonia  is 
apt  to  ensue.  If  these  patients  temporarily  cannot  swallow  as 
occasionally  occurs  nourishment  is  given  by  stomach  tube.  In 
scabbard  trachea  discomfort  due  to  the  distortion  of  the  trachea 
will  persist  for  some  time. 

After  Care  of  Enucleation  of  Thyroid  Tumors  (adenomata  and 
cysts). — The  wound  is  drained  and  a  copious  dressing  applied. 
In  this  and  in  similar  operations  involving  more  or  less  trauma- 
tism to  the  substance  of  the  gland,  in  spite  of  most  careful 
hemostasis  during  the  operation  oozing  will  follow.  If  more 
severe  hemorrhage  occurs,  perhaps  caused  by  post-anesthetic 
vomiting,  the  blood  wUl  first  fill  the  cavity  in  the  gland  from 
which  the  tumor  has  been  removed  and,  if  drainage  is  not  free, 
will  then  extend  beneath  the  deep  fascia.  In  the  latter  event 
there  will  be  danger  of  asphyxia.  Treatment  consists  of  the  re- 
moval of  a  sufficient  number  of  the  sutures  to  permit  the  free 
escape  of  the  effused  blood. 

Escape  of  gland  secretion  may  occur  in  cases  in  which  there  is 
much  tearing  of  the  gland  tissue.  The  secretion  escapes  into 
the  tissues  of  the  neck  and  forms  a  soft  swelling  in  and  around 
the  gland  if  drainage  is  inefficient.  If  rapidly  absorbed,  symp- 
toms of  acute  th}Toidism  will  appear.  The  treatment  is  to  open 
the  wound  and  provide  efficient  drainage. 

Complications  due  to  Interference  with  the  Function  of  the 
Thyroid  and  Parathyroid  Bodies.  Tetany. — ^Fortunately  this 
complication  is  rarely  seen  at  the  present  time;  formerly  it  was 
a    common    complication    following    thyroidectomy    and    was 


OPERATIONS    ON    THE    NECK  419 

thought  to  be  due  to  the  removal  of  the  entire  gland;  but  now 
it  is  known  to  follow  only,  and  not  necessarily  always,  the  removal 
of  the  parathyroid  bodies. 

When  this  fact  became  recognized  the  technic  of  thyroidectomy 
was  improved  to  safeguard  the  parathyroids  by  leaving  the  outer 
and  posterior  portion  of  the  capsule.  According  to  the  latest 
statistics  the  complication  now  occurs  in  less  than  one-half  of 
one  per  cent,  of  cases;  even  this  for  a  preventable  complication 
would  seem  high. 

Tetany  first  makes  its  appearance  a  few  days  following  the 
operation.  The  first  symptoms  usually  appear  in  the  upper 
extremities;  a  tingling  or  twitching  of  the  muscles  may  be  first 
noted,  convulsive  seizures  follow,  the  fingers  are  first  flexed  and 
then  rigidly  contracted;  the  wrist  and  elbow  are  flexed  and  the 
knee  and  hip  extended.  The  feet  are  in  plantar  flexion  and  supi- 
nated.  The  muscular  contractures  are  tonic,  continue  for  a  vari- 
able length  of  time,  and  recur  at  intervals.  The  muscles  of  the 
face  and  neck  may  become  involved.  Formerly  in  about  60  per 
cent,  of  the  cases  death  followed  in  a  few  days.  The  diaphrag- 
matic muscles  are  at  times  involved.  The  onset  of  this  compli- 
cation sometimes  occurs  at  the  end  of  weeks  or  months  following 
the  operation.  If  the  patient  survives  the  first  few  days  the 
tetany  may  rapidly  subside  after  a  duration  of  eight  to  fifteen 
days;  in  some  cases  it  is  prolonged  for  months  and  years  with  re- 
missions. Finally  death  results  from  respiratory  paralysis. 
Occasionally  a  case  will  recover. 

Treatment. — As  soon  as  the  first  symptoms  appear  the  patient 
should  be  given  parathyroid  gland  extracts;  the  diet  should  be 
light  and  low  in  nitrogen.  Elimination  should  be  increased  by 
active  stimulation  of  excretion  through  the  skin,  bowel  and 
kidneys.  Saline  infusion  is  useful  in  diluting  the  toxemia  and 
increasing  the  elimination.  Transfusion  will  temporarily  check 
the  symptoms.  Intravenous  saline  infusion  acts  in  the  same 
manner.  Feeding  with  parathyroid  glands  and  injection  or 
parathyroid  emulsion  temporarily  and  often  rapidly  stops  the 
symptoms.  Following  any  of  these  methods  the  symptoms  may 
be  held  in  abeyance  for  twenty-four  hours.  The  use  of  these 
measures,  however,  will  probably  not  prove  of  any  permanent 


420  OPERATING    ROOM    AXD    THE    PATIENT 

value  should  all  of  the  parathyroids  have  been  removed,  but  if, 
as  is  conceivable,  one  or  more  of  the  parathyroids  were  removed 
and  the  remaining  ones  traumatized  during  the  operation,  then, 
in  the  event  of  the  development  of  tetany,  the  above  mentioned 
measures  would  be  of  extreme  value  in  tiding  the  patient  over 
until  the  traumatized  parathyroids  resumed  theh  function. 

Beehe's  nucleo-proteid  is  of  value  particularly  when  combined 
with  parathyroid  feeding;  fresh  ox  parathyroids  are  used.  The 
administration  of  soluble  calcium  salts  will  quickly  stop  severe 
tetanic  sjmiptoms.  In  a  case  of  Halstead's  in  which  the  admin- 
istration of  parathyroid  gland  extracts  had  averted  tetany  for 
two  years,  the  attacks  were  also  averted  during  the  third  year 
by  the  use  of  calcium  salts. 

Experimental  transplantation  of  parathyroids  in  animals  has 
proved  successful  in  about  60  per  cent,  of  cases  according  to 
Halstead.  In  some  of  his  experiments  a  beginning  tetany  was 
tided  over  by  the  administration  of  calcium  salts.  Eiselsberg 
transplanted  a  parathyroid  in  a  woman  who  had  suffered  for 
many  years  from  severe  tetany  following  parathyroid  extirpation. 
In  Kocher's  experiments  transplantations  into  the  tibia  are  made 
in  two  stages;  first  the  tibia  is  opened  and  a  small  cavity  made 
by  forcing  a  silver  ball  into  the  marrow;  the  wound  is  then 
closed.  After  several  days  when  granulations  have  formed  the 
silver  ball  is  removed  and  fresh  gland  tissue  implanted  in  the 
resulting  cavity.  In  this  manner  interference  by  hemorrhage  is 
avoided.  Kocher  found  that  this  method  proved  efficacious  in 
dogs.  One  of  his  most  interesting  observations  is  that  resection 
of  the  bone  containing  the  implanted  tissue  quickly  caused  death 
from  acute  tetany. 

Myxedema  (cachexia  strumipriva)  develops  slowly  and  for 
this  reason  seldom  comes  under  the  notice  of  the  surgeon  as  the 
case  has  long  since  passed  from  under  his  observation.  Only 
rarely  does  an  acute  myxedema  develop.  Usually  it  is  months 
before  the  disease  is  noticed.  The  most  marked  early  symptom 
is  increasing  anemia.  Gradually  all  parts  of  the  body  become 
affected.  The  skin  is  at  first  waxy  and  pale;  later,  owing  to  the 
almost  complete  inhibition  of  the  sweat  and  sebaceous  glands 
the  skin  becomes  dry  and  fissured.     Following  this  the  skin  be- 


OPERATION'S    ON    THE    NECK  421 

comes  thick  and  brawny  due  to  an  edema  which  affects  the  entire 
body;  this  edema  is  general  and  does  not  pit  upon  pressure.  It 
has  no  resemblance  to  nephritic  edema  and  cannot  be  massaged 
away.  The  hair,  particularly  of  the  head  and  pubes,  falls  out. 
A  curious  fact  in  this  connection  is  the  growth  of  coarse  hair  in 
parts  of  the  body  which  are  normally  free  from  hair.  The  body 
temperature  is  lowered,  the  skin  is  cool.  In  the  majority  of 
cases  the  pulse  is  slowed,  though  in  rare  instances  it  may  be  in- 
creased. The  amount  of  urine  is  diminished  and  its  specific 
gravity  is  below  normal.  More  marked  even  than  the  bodily 
changes  is  the  change  in  mentality.  Slowly  but  steadily  the  in- 
telligence of  these  unfortunate  patients  disappears;  the  speech 
becomes  slow  and  stuttering;  movements  become  uncertain; 
memory  is  lost;  the  features  are  dull  and  apathetic.  The  proc- 
ess is  a  slow  one  and  may  continue  for  years,  the  patient  finally 
dying  from  gradually  increasing  cachexia. 

Cases  in  which  an  accessory  thyroid  is  present  or  m  which  a 
portion  of  the  thyroid  is  left  may  present  the  early  symptoms  of 
myxedema  but  upon  the  hypertrophy  of  the  remaining  thyroid 
tissue  these  symptoms  will  gradually  disappear. 

Treatment.  Thyroid  Therapy. — Malignant  disease  constitutes 
the  sole  indication  for  the  entire  removal  of  the  thyroid  gland. 
Such  cases,  and  in  cases  in'  which  but  a  small  portion  of  the 
gland  has  been  left,  are  to  be  watched  carefully.  In  the  first 
instance  it  is  better  to  begin  thyroid  feeding  at  once;  in  the 
second  as  soon  as  it  becomes  apparent  that  the  amount  of 
thyroid  tissue  remaining  will  not  be  hypertrophied  sufficiently 
to  provide  the  secretion  necessary  for  metabolism.  By  means  of 
thyroid  feeding,  we  may  hope  to  avert  indefinitely  the  changes 
which  inevitably  follow  the  removal  of  all  thyroid  tissue.  In 
many  cases  this  treatment  will  prove  successful.  In  cases  in 
which  symptoms  of  myxedema  have  already  appeared  feeding 
will  prevent  an  increase  of  the  symptoms  and  cause  their  gradual 
disappearance.  The  secretions  become  normal,  there  is  an 
increase  in  weight  and  the  mentality  is  improved.  The  final 
condition  of  the  patient  becomes  quite  normal.  Whether 
this  is  true  in  every  case  it  is  impossible  to  state  at  the  present 
time.     The    treatment    must    be    continued    indefinitely.     At 


422  OPERATING    ROOM    AND    THE    PATIENT 

intervals  of  weeks  or  months  the  treatment  may  be  discontinued 
for  a  time  if  there  are  no  symptoms  in  order  to  determine  if 
hypertrophy  of  remaining  thyroid  tissue  or  accessory  gland  has 
occurred.     Upon  the  occurrence  of  any  symptoms  treatment  is 
to  be  immediately  begun.     Chloral  hydrate  is  a  useful  adjunct 
to  thyroid  feeding.     The  implantation  of  normal  thyroid  tissue 
is  the  ideal  treatment  but  naturally  presents  great  obstacles. 
The  conditions  necessary  for  success  are,   a  fresh  portion   of 
active  gland  and  ^  favorable  implantation  soil  (Kocher).  Admin- 
istration of  thyroid  preparation.     As  the  secretion  of  the  thyroid 
gland  in  large  doses  is  a  powerful  poison,  care  must  be  exercised 
in  its  administration.     The  dosage  must  be  determined  in  the 
individual  case.     The  fresh  gland  was  formerly  given  twice  a 
week,  one-half  a  sheep  thyroid  at  a  dose,  cut  up  raw  and  spread 
on  bread.     This  was  made  more  palatable  by  the  addition  of  a 
little  pepper  and  salt.     At  the  present  day  a  dried  extract  of 
the  gland  is  prepared  in  tablet  form.     Each  tablet  represents  five 
grains  of  the  dried  gland.     The  dose  of  this  dried  extract  is  one 
tablet  given  after  a  full  meal  once  a  day  for  several  days;  if  no 
bad  symptoms  are  noted  a  tablet  may  be  given  twice  a  day. 
The  number  may  subsequently  be  increased  to  from  three  to 
five  tablets  a  day.     The  actual  strength  of  the  extract  varies 
according  to  its  manufacture.     A  more  staple  preparation  is 
thyroiodin    (three   grains  of  iodin  and  one  grain  of  the  dried 
gland)    or  thyroid  colloid,  the  active  principle  of  the  thyroid 
gland.     The  dose  of  the  latter  is  one-half  to  one  grain  but  it  is 
better  to  begin  with  the  smaller  dose  and  test  the  tolerance  of 
the  patient  before  giving  larger  doses.     Should  an  overdose  be 
given  very  alarming  symptoms  will  arise.     A  single  dose  may 
prove  too  large  or  a  series  of  moderate  doses  may  prove  cumula- 
tive.    Acute  thyroidism  will  develop.     The  temperature  rises 
rapidly,  the  pulse  becomes  rapid,  small  and  irregular;  there  is 
headache,    vertigo,    nausea,  pains  in  the  joints  and  muscular 
tremors.     Upon  the  appearance  of  these  symptoms  the  drug  is 
to  be  discontinued  at  once. 

Torticollis. — Irrespective  of  the  character  of  the  operation, 
whether  on  muscles  and  fascia  or  nerves  or  both,  a  final  cure  will 
depend  upon  the  after-treatment.     At  the  operation  the  condi- 


OPERATIONS    ON    THE    NECK  423 

tion  is  remedied,  the  position  of  the  head  overcorrected  and  a 
well-padded  plaster-of-Paris  splint  applied. 

If  the  deformity  has  not  long  been  present  and  consequently 
but  slight  organic  change  in  the  muscles  and  fascia  has  taken 
place  the  plaster  may  be  omitted  and  the  proper  position  main- 
tained by  sandbags  for  seven  to  ten  days  when  the  sutures  are 
removed.  In  such  cases  apparatus  may  be  dispensed  with 
and  passive  and  active  motion  and  manipulation  be  commenced. 
Usually  this  is  sufficient  to  effect  a  cure. 

In  cases  of  longer  standing  and  in  young  children  a  head 
extension  is  applied,  a  weight  of  three  to  five  pounds  being 
usually  sufficient,  and  the  head  of  the  bed  raised  sufficiently  high 
to  cause  the  body  to  form  the  counterextension.  The  head 
is  fixed  by  sandbags  placed  to  either  side.  This  position  is 
maintained  for  two  to  three  weeks.  If  the  patient  is  restless 
it  will  be  necessary  to  apply  a  molded  plaster  splint  to  the 
head,  neck  and  shoulders.  In  the  mild  cases  two  or  three 
weeks  extension  is  sufficient  and  manipulation  and  passive 
and  active  motion  may  then  be  commenced. 

In  the  more  severe  cases  after  removal  of  the  plaster  splints, 
in  addition  to  massage  and  passive  and  active  motion,  a  Sayre 
apparatus  should  be  applied.  This  consists  of  two  circlets, 
one  for  the  head  and  one  for  the  chest,  connected  by  a  stout 
rubber  band  one  end  of  which  is  attached  to  the  head  circlet 
close  to  the  mastoid  process  on  the  sound  side,  the  other  end 
attached  to  the  chest  circlet  close  to  the  anterior  axillary  fold 
on  the  same  side.  This  maintains  a  constant  elastic  pull  against 
the  deformity.  It  may  be  necessary  to  carry  out  the  treatment 
for  several  months.  Upon  final  removal  of  the  apparatus, 
regular  calisthenic  exercises  (not  violent  exercises)  should  be 
instituted.  These  directions  will  be  better  followed  out  if  the 
patient  attends  a  gymnasium. 

If  the  case  is  one  of  spastic  torticollis  it  will  be  more  difficult 
to  maintain  the  head  in  proper  position.'  In  such  cases  it  is 
better  to  apply  the  molded  plaster  splints  under  anesthesia 
directly  after  the  operation  and  after  several  weeks  to  employ 
Sayre's  apparatus. 


424  OPERATING    ROOM    AXD    THE    PATIEXT 

CH.\PTER  XV. 

OPERATIONS  UPON  THE  THORAX. 

Typical  Operation  for  Carcinoma  Mammae.  Retentive  and 
Supporting  Dressing. — In  dressing  such  an  extensive  wound  as 
that  following  typical  excision  of  the  breast,  pectoralis  major 
and  minor,  and  removal  of  the  glands  and  fatty  tissue  of  the 
axillary  and  supraclavicular  spaces,  great  difficulty  is  met  with. 
But  this  may  be  overcome  with  the  dexterity  coming  from  prac- 
ticing this  as  well  as  other  dressings  and  bandages  upon  the  model. 
The  chief  difficulty  met  with  in  dressing  a  wound  the  result  of 
an  extensive  operation  for  carcinoma  mammre  lies  in  obliter- 
ating the  large  dead  spaces,  supporting  and  relieving  the  tension 
on  the  skin  flaps,  and  immobilizing  the  arm  and  shoulder  of  the 
affected  side.  If  loosely  applied  the  dressing  does  not  fulfil  these 
indications.  If  tightly  applied,  respiration  is  embarrassed  or  a 
mastitis  of  the  remaining  breast  may  result.  A  dressing  which 
exerts  slight,  constant  elastic  pressure  is  an  ideal  one.  The  choice 
of  a  retentive  dressing  is  between  bandages  and  the  breast  binder. 
In  any  event  the  shoulders  and  upper  half  of  the  abdomen 
should  be  included.  The  material  emploj^ed  should  be  un- 
bleached muslin.  Bandages  are  objectionable  as  a  rule  for  the 
primary  dressing,  for  they  require  an  amount  of  shifting  of 
the  patient  which  is  arduous,  particularly  if  the  patient  be  a 
heavy  individual.  Moreover,  they  cannot  be  made  to  fit  snugly 
nor  exert  even  pressure  while  the  patient  is  in  the  semi-uncon- 
scious state  of  anesthesia.  Bandaging  may  be  used,  however, 
at  subsequent  dressings  when  the  movements  of  the  patient  can 
be  better  controlled.  If  used  for  the  primary  dressing,  the  chest 
and  abdominal  turns  should  be  applied  with  the  patient  in  the 
dorsal  position.  For  the  shoulder  and  arm  turns  the  shoulders 
are  to  be  elevated.  To  facilitate  bandaging,  the  Yolkmann  block 
may  be  employed  with  advantage. 

A  breast  binder  will  be  found  to  better  comply  with  the 
indications.  One  that  will  fit  the  patient  is  selected  and  steril- 
ized with  the  wound  dressings. 


OPERATIONS    UPON    THE    THORAX  425 

Primary  Wound  Dressing. — Plain  gauze  compresses  in  a  dry 
state  are  shaken  out,  and  with  the  patient's  arm  abducted  to 
twenty  degrees,  are  packed  closely  in  the  apex  of  the  axilla  and 
between  the  abducted  arm  and  the  lateral  chest  wall,  so  as  to  fill 
the  space  between  the  abducted  arm  and  the  chest  down  to  the 
level  of  the  lower  third  of  the  upper  arm.  The  suture  line  is 
covered  with  compresses  folded  flat,  care  being  taken  that  the 
ends  of  the  sutures  lie  flat  against  the  skin,  to  guard  against 
irritation  from  this  source.  If  much  tension  exists,  the  flaps 
may  be  further  supported  by  broad  adhesive  plaster  straps. 
Flat  layers  of  gauze  cover  the  chest  wall,  shoulder  and  upper  arm 
of  the  affected  side.  Over  all  and  in  the  axilla  of  the  opposite 
side  is  placed  a  thick  even  layer  of  non-absorbent  cotton.  This 
latter  not  only  protects  the  parts,  but  aids  in  exerting  the  elastic 
pressure  necessary.  During  the  manipulations  incident  to  the 
application  of  the  dressing,  one  assistant  should  devote  his 
entire  attention  to  keeping  the  axillary  pack  in  position  by 
controlling  the  movement  of  the  partially  abducted  arm. 

Application  of  the  Binder.— The  body  of  the  binder  is  placed 
beneath  the  patient  and  the  lateral  edges  brought  to  the  median 
line  in  front,  where  they  are  pinned  temporarily.  The  shoulder 
piece  of  the  unoperated  side  is  fitted  and  pinned  temporarily, 
then  the  long  shoulder  piece  of  the  affected  side  is  brought  over 
the  shoulder,  down  the  front  of  the  binder,  between  the  abducted 
arm  and  the  lower  lateral  chest  wall  and  carried  smoothly  up 
over  the  posterior  surface  of  the  binder  to  its  starting  point. 
The  opposite  shoulder  strap  is  then  fastened.  The  temporary 
pins  are  now  removed  and  the  remaining  breast  supported  and 
held  flat  against  the  chest  wall  while  the  front  of  the  binder  is 
snugly  pinned.  The  forearm  of  the  affected  side  is  secured  by  a 
sling  fastened  to  the  binder.  Before  applying  this  the  circulation 
is  supported  by  bandaging  the  hand,  wrist  and  forearm  as  far  as 
the  elbow.  When  the  patient  has  been  placed  in  bed,  soft 
pillows  support  the  shoulder  and  the  arm  of  the  operated  side. 

Primary  Complications. — More  or  less  discomfort  is  incident  to 
the  first  twenty-four  hours.  This  will  lessen  as  the  pain  from  the 
traumatism  of  the  operation  subsides.  Venous  congestion  of  the 
extremity  may  result  if  the  dressing  has  been  inefficiently  applied, 


426  OPERATING    ROOM    AND    THE    PATIENT 

or  if  lateral  branches  of  the  axillary  vein  have  been  tied  close  to 
the  vein,  or  if  a  lateral  ligation  of  the  axillary  or  subclavian  vein 
has  been  necessary.  Associated  with  congestion  there  is  decided 
pain  along  the  arm.  If  congestion  and  pain  persist,  the  binder 
may  be  slightly  loosened.  Edema  may  develop  as  a  result  of 
continued  pressure,  or  in  the  cases  in  which  ligation  of  the  axillary 
or  subclavian  vein  has  been  necessitated  by  cancerous  growth 
involving  the  vessel  wall.  If  due  to  continued  pressure,  the 
binder  is  still  further  loosened,  and  the  hand  and  forearm 
rebandaged.  If  due  to  ligation,  the  condition  may  be  alleviated 
by  supporting  bandages  and  massage.  Massage,  except  for  the 
hand  and  forearm,  must  not  be  instituted  while  there  is  any 
danger  of  disturbing  the  process  of  wound  healing.  Soreness  of 
the  Opposite  Axilla. — The  secretions  of  the  hair  and  sweat  follicles 
of  the  healthy  side  may  collect  under  the  protecting  cotton  and 
not  only  cause  local  irritation,  but,  theoretically  at  least,  lead  to 
infection  of  the  wound  by  the  bacillus  pyocyaneus,  whose  normal 
habitat  is  in  the  axilla.  This  is  prevented  by  daily  cleansing  of 
the  axilla  without  disturbing  the  binder. 

Mastitis  of  the  remaining  breast  is  an  occasional  complication. 
It  is  due  to  traumatism  from  badly  fitting  dressings.  The 
treatment  is  support  of  the  breast  and  application  of  atropin- 
giycerin  solution.     Later  very  gentle  massage  is  of  value. 

Disturbance  of  Drainage. — If  drainage  has  been  employed,  the 
tube  or  gauze  drain  is  usually  brought  out  through  a  supple- 
mentary opening.  Its  presence  serves  to  prevent  collections  of 
serum  from  forming,  but  this  is  usually  equally  well  done  by 
the  proper  application  of  the  primary  dressing  without  the 
disadvantage  possessed  by  the  tube  or  gauze  drain.  The  drain 
is  removed  at  the  end  of  forty-eight  hours.  In  the  event  of 
palpable  wound  infection,  such  as  broken-down  axillary  glands, 
drainage'  is  necessary.  Its  use  in  such  cases  must  be  prolonged 
until  infection  subsides.  Redressing. — After  seventy-two  hours 
the  binder  may  be  loosened  and  movements  of  the  elbow  en- 
couraged. This  also  allows  of  slight  movements  of  the  shoulder 
but  not  enough  to  interfere  with  wound  healing.  The  wound 
dressing  is  not  to  be  disturbed,  except  as  noted  above  or  to  meet 
complications  which  may  arise  in  any  wound,  infection,  untU 


OPERATIONS  UPON  THE  THORAX  427 

the  tenth  day.  The  binder  and  the  entire  dressing  are  carefully 
removed,  the  arm  being  supported  by  an  assistant,  the  patient 
sitting.  The  sutures  are  removed.  The  skin  of  the  axilla  and 
those  parts  which  have  been  covered  by  the  dressing  is  sponged 
with  alcohol  and  dried,  with  the  exception  of  the  skin  in  imme- 
diate proximity  to  the  wound.  This  sponging  proves  particularly 
grateful  to  patients  and  adds  greatly  to  their  comfort.  The 
tender  cicatrix  is  supported  by  strapping  and  a  flat  gauze  dressing 
applied.  A  fresh  binder  is  applied  but  the  arm  is  placed  outside 
the  binder  and  a  separate  dressing  applied  to  the  scar  on  the 
arm.  This  allows  of  free  shoulder  movements.  The  forearm  is 
supported  by  a  sling.  Small  granulating  surfaces  the  result  of 
imperfect  wound  approximation  are  treated.  Surfaces  the 
result  of  separation  of  the  wound  edges  due  to  tension  of  the 
flaps  are  covered  with  Thiersch  skin-grafts  if  this  was  not  done 
at  the  time  of  the  operation.  In  uncomplicated  cases  healing 
is  complete  on  the  fourteenth  day.  Woimd  complications  are 
those  common  to  all  wounds.  One  would  expect  with  such  an 
extensive  wound  complications  in  the  healing  process,  but  under 
aseptic  technic  such  occurrences  are  extremely  rare.  The 
hacilhis  pyocyaneus,  whose  natural  habitat  is  the  axilla  and  the 
groin,  is  so  easily  destroyed  by  the  ordinary  disinfection  by 
bichlorid  of  mercury  that  it  rarely  infects  the  wound.  Should 
infection  occur  it  is  to  be  combated  by  the  usual  means. 

General  Care  of  the  Patient. — The  patient  may  be  allowed  to 
sit  up  in  bed  on  the  first  or  second  day  following  the  operation, 
allowed  in  a  chair  on  the  third  or  fourth  day,  and  on  the  day 
following  to  walk  about.  Movements  of  the  fingers,  hand  and 
wrist  are  encouraged  after  forty-eight  hours  and  movements  of 
the  elbow  after  seventy-two  hours.  Slight  shoulder  movements 
are  encouraged  at  the  same  time.  Following  removal  of  the 
sutures  passive  and  active  movements  of  the  shoulder  are  insti- 
tuted so  that  by  the  twenty-first  day  patients  are  able  to  place  the 
palm  of  the  hand  on  the  top  of  the  head.  It  is  advisable  in  hard- 
working patients,  or  those  with  a  gouty  diathesis,  to  prescribe 
daily  massage  of  the  fingers  throughout  this  period. 

Contraction  of  the  Cicatrix. — After  the  second  week  contraction 
of  the  scar  tissue  begins  to  be  manifest.     It  must  be  remembered 


428  OPERATIXG    ROOM    AXD    THE    PATIENT 

that  in  such  an  operation  as  we  have  under  consideration  there 
has  been  a  considerable  loss  of  muscular  substance.  This  does 
not  mean  that  the  movements  of  the  shoulder  and  arm  will  b6 
interfered  with  as  regards  range  of  motion,  for  the  deltoid  and 
coraco-brachialis  muscles  take  upon  themselves  the  drawing 
of  the  arm  forward  and  inward,  movements  in  which  before 
removal  of  the  pectoralis  major  they  served  to  assist  that  muscle, 
but  the  strength  of  these  movements  is  largely  impaired  at  first. 
A  compensating  hypertrophy  later  takes  place,  which  materially 
decreases  the  loss  of  power  in  these  movements.  The  primary  dis- 
ability of  the  arm  does  not  depend  upon  this,  however,  but  upon 
the  cicatrix,  which  may  prevent  abduction,  and  it  is  important 
at  the  time  of  operation  that  the  incision  should  be  so  placed  as 
to  interfere  subsequently  as  little  as  possible  with  abduction  of 
the  arm.  The  abducted  position  of  the  arm,  as  described  in  the 
primary  dressing,  still  further  guards  against  disability  from  this 
source.  To  still  further  obviate  this  contraction,  early  use  of  the 
arm  is  to  be  insisted  on.  An  additional  cause  of  disability  is 
found  in  the  adhesions  formed  in  the  axilla  by  the  removal  of  the 
glands  and  fatty  tissue  therefrom.  These  adhesions,  by  subse- 
quent contraction,  may  cause  edema  if  the  vein  is  involved,  or  a 
very  'painful  condition  of  the  arm  if  the  brachial  plexus  is  involved. 
If  suppuration  has  intervened,  disability  from  contraction  will 
be  more  marked.  On  the  removal  of  the  sutures  gentle  passive 
motion  is  to  be  instituted,  and  gradually  increased  and  supple- 
mented by  active  movements  of  the  arm.  The  final  condition  of 
the  patient  in  cases  in  which  the  after-treatment  has  been  rigidly 
enforced  may  be  such  as  to  show  no  loss  of  motion  and  but 
slight  loss  of  power.  If,  however,  a  large  amount  of  scar  tissue 
has  formed,  the  outlook  is  not  so  favorable.  The  edema  and  pain 
produced  by  scar  formation  and  contraction  in  the  axilla  may 
be  such  as  to  demand  excision  of  the  mass  of  scar  tissue,  or  this 
failing,  even  amputation  of  the  arm. 

Lymphatic  Edema. — On  account  of  the  removal  of  the  lymph- 
atic glands  in  the  axilla,  there  may  follow  a  condition  of  lympho- 
stasis  in  the  arm.  This  occurs  independently  of  any  compression 
of  the  axillary  vein.  A  condition  of  the  skin  may  ensue  similar 
to   that    found    in    elephantiasis.       Bandaging    and    massage, 


OPERATIONS    UPON    THE    THORAX  429 

usually  cause  its  subsidence;  if  not,  lyniphangioplasty  may  be 
done. 

Keloid. — This  affection  of  the  scar  is  particularly  prone  to 
occur  after  operation  upon  the  chest  wall. 

Recurrence. — Recurrence  of  -the  disease  is  to  be  carefully 
watched  for.  It  may  occur  at  any  time,  from  a  few  weeks  to 
many  years.  During  the  first  six  months  the  patient  should 
be  examined  monthly,  after  this  every  two  months  for  a  consider- 
able time,  and  finally  should  be  instructed  to  report  immediately 
on  any  untoward  general  symptoms  or  upon  the  growth  of  any 
nodule  in  the  scar  or  elsewhere.  Local  recurrences  are  to  be 
extirpated  without  delay  and  as  often  as  they  recur.  General 
metastasis  is  to  be  treated  by  measures  calculated  to  alleviate 
as  far  as  possible  the  condition  of  the  patient. 

Amputation  of  the  Breast. — As  the  dissection  here  is  not 
extensive  and  the  flaps  ample  it  is  not  necessary  to  immobilize 
the  shoulder  of  the  affected  side.  Flat  gauze  compresses  with 
broad  straps  of  adhesive  plaster  to  exert  even  pressure  form  the 
primary  wound  dressing.  A  snug  fitting  breast  binder  serves  to 
support  the  remaining  breast.  The  arm  of  the  operated  side  is 
carried  in  a  sling. 

Resection  of  the  Breast. — When  a  segment  of  the  breast  is 
removed  or  a  tumor  enucleated  the  resulting  cavity  must  be 
obliterated  by  pressure.  To  accomplish  this  flat  gauze  com- 
presses are  laid  about  the  breast  and  built  up  to  exert  even 
pressure.  These  are  held  in  place  by  adhesive  plaster  straps 
and  a  very  snug-fitting  breast  binder  applied.  The  arm  is 
supported  by  a  sling. 

Suppurative  Mastitis. — If  the  disease  has  involved  most  of 
the  breast  tissue  (multiple  abscesses),  amputation  will  probably 
have  been  performed.  In  such  a  case,  if  the  incision  has  been 
wide  of  infected  tissue,  primary  union  will  result.  If  it  has  been 
impossible  to  keep  entirely  clear  of  the  infected  area,  the  wound 
will  have  been  closed  in  part  only  and  secondary  suturing  will 
be  necessary.  If  only  a  segment  of  the  breast  is  involved 
(simple  abscess  or  submammary  abscess),  the  treatment  will 
be  as  for  abscess.  If  radiating  incisions  have  been  practised 
for  multiple  abscess,  rigorous  disinfection  must  be  done  daily, 


430  OPERATING    EOOM    AND    THE    PATIENT 

and  unopened  pus  foci  continually  sought  for  and  drained. 
Cavities  should  be  irrigated  with  a  mild  antiseptic  solution, 
dried,  Bier's  hyperemia  applied  for  five  to  fifteen  minutes,  the 
cavities  again  dried  and  filled  with  balsam  of  Peru  and  olive  oil. 
The  incisions  are  kept  wide  open  by  packing  or  soft  drainage 
tubes  and  an  absorbent  gauze  dressing  applied.  The  breast  is 
supported  but  pressure  is  contraindicated  during  the  height  of 
the  infection.  The  dressing  is  repeated  frequently  enough  to 
avoid  stagnation  of  secretions.  A  culture  should  be  made  at 
the  time  of  operation  and  a  vaccine  prepared  and  administered. 
The  after-course  is  usually  tedious.  Abscess  usually  occurs 
during  lactation.  If  the  abscess  is  small  the  child  may  nurse 
from  the  other  breast.  If  multiple  abscesses  are  present  the 
process  of  lactation  should  be  stopped. 

Lacteal  fistula  may  persist  on  account  of  the  presence  of  pus 
and  infected  granulations.  Thorough  curetting  and  repeated 
cauterization  Avith  silver  nitrate  will  effect  a  cure. 

Should  the  condition  of  multiple  mammary  fistulce  be  present, 
in  which,  through  neglect  early  in  the  case,  multiple  foci  of 
suppuration  have  formed  and  the  function  of  the  gland  is  prac- 
tically destroyed  by  cicatricial  contraction  and  obliteration  of 
the  lactiferous  ducts  and  acini,  and  in  which  the  fear  of  super- 
vention of  fibrous  carcinoma  (scirrhus)  may  be  reasonably 
entertained,  extirpation  of  the  mamma  is  to  be  resorted  to. 

Subpectoral  Abscess. — The  after-treatment  is  particularly 
wearisome.  Tuberculous  infection  is  usually  the  cause.  Such 
abscesses,  to  be  cured,  must  not  only  be  incised  and  curetted,  but 
all  infected  tissue  must  be  removed;  otherwise  a  long-continued 
process  of  suppuration  wiU  follow,  resulting  in  the  formation  of 
extensive  scar  tissue,  the  subsequent  contraction  of  which 
greatly  disables  the  arm.  If  such  an  abscess  has  opened  spon- 
taneously or  has  been  inadequately  incised  under  a  mistaken 
idea  that  a  cure  will  result,  it  is  necessary  to  make  a  free  incision 
and  follow  up  and  dissect  out  all  of  the  sinus  and  the  scar  tissue. 
Passive  and  active  motion  should  begin  on  the  third  day  follow- 
ing operation  and  must  be  continued  conscientiously  if  a  favor- 
able result  is  to  be  hoped  for. 

Fracture  of  Ribs. — A  supporting  dressing  of  adhesive  plaster 


OPERATIONS  UPON  THE  THORAX  431 

is  applied,  extending  slightly  beyond  the  middle  line  in  front  and 
back  and  a  chest  bandage  applied.  The  progress  of  healing 
depends  upon  the  existence  of  other  complicating  injuries, 
particularly  inj  uries  to  the  lung.  Such  complications  may  demand 
operative  treatment.  The  stabbing  pains  produced  by  the 
respiratory  movements  of  the  chest  wall  are  remedied  by  the 
restraining  effect  of  the  adhesive  plaster  dressing.  The  dorsal 
position  may  not  be  tolerable,  and  a  semi-reclining  position  may 
have  to  be  maintained.  The  ice-bag  will  serve  to  relieve  ex- 
cessive pain.  If  cough  is  persistent,  some  preparation  of  opium 
should  be  used  to  control  it.  Usually  the  healing  process  is 
uneventful.  Union  is  complete  in  from  fourteen  to  eighteen  days, 
and  the  dressing  may  then  be  removed.  If  a  floating  rib  has 
been  fractured,  and  this  is  rare,  union  will  in  all  probability  not 
result.  In  such  a  case  if  pain  persists,  the  distal  portion  or,  in 
fact,  most  of  the  rib  may  be  excised. 

Resection  of  the  Ribs. — The  retentive  dressing  is  the  same  as 
for  fracture  of  the  ribs.  The  danger  of  dislocation  of  severed 
bone  surfaces  is  not  to  be  apprehended.  These  surfaces  approach 
each  other  somewhat.  If  the  operation  has  been  a  superiosteal 
one,  new  bone  will  fill  the  intervening  space  and  even  bridges 
over  to  the  adjoining  ribs.  No  functional  defect  will  result 
unless  a  considerable  extent  of  several  ribs  has  been  removed. 

Resection  of  the  Sternum. — Mediastinitis  may  complicate  this 
operation  as  a  result  of  infection  at  the  operation  or  at  subse- 
quent dressing. 

In  rib  or  sternal  resection  if  performed  for  caries  a  fistula  is 
likely  to  result.  Infection  from  caries  may  follow  the  course  of 
the  rib  and  an  abscess  point  at  some  distance  from  the  original 
site  of  the  primary  disease.  The  site  of  the  primary  focus  on  the 
inner  aspect  of  the  rib  may  render  the  search  for  it  difficult. 

Treatment. — The  usual  treatment  for  fistulse  by  curettage  and 
the  injection  of  antiseptics  does  little  good  in  such  cases.  Spon- 
taneous closure,  if  it  occurs  at  all,  takes  place  only  after  a  long 
period  and  following  the  discharge  of  carious  bone  or  the  healing 
in  of  the  diseased  portion.  Temporary  closure  may  occur  from 
time  to  time.  The  only  rational  treatment  is  freely  opening  the 
irregular  sinuses  and  tracing  them  to  their  source.     The  deeply 


432  OPERATING    ROOM    AND    THE    PATIENT 

situated  focus  of  disease  must  be  actually  seen  in  order  to  remove 
it  thoroughly.  Such  wounds  are  packed  and  allowed  to  heal  by 
granulation. 

Pleuritis  may  complicate  operations  on  the  soft  or  bony  parts 
of  the  chest  wall  if  such  wounds  become  infected,  particularly  if 
the  pleura  has  been  opened  at  the  time  of  operation,  either 
accidentally  or  otherwise.  Pericarditis  may  also  result.  Should 
fever  persist  after  an  operation  of  this  character,  such  com- 
plications are  to  be  thought  of. 

Paracentesis  Thoracis. — In  large  effusions  the  intercostal  spaces 
are  usually  prominent  and  the  puncture  is  easily  made.  The 
index-finger  of  the  left  hand  is  pressed  in  the  intercostal  space 
selected  (usually  one  j.ust  below  and  in  a  line  with  the  angle  of  the 
scapula),  and  the  point  of  the  needle  is  brought  in  contact  with 
the  skin  and  at  right  angles  to  the  ribs.  The  pressure  of  the 
finger  in  the  intercostal  space  in  the  neighborhood  of  the  needle- 
point prevents  deviation  of  the  needle  if  the  patient  should 
involuntarily  move  as  the  needle  enters  the  skin.  If  this  is  not 
done,  involuntary  movement  of  the  patient  may  cause  the  point 
of  the  needle  to  strike  a  rib.  Guarded  by  the  forefinger  lying 
along  the  needle  the  latter  is  thrust  quickly  into  the  chest  for  the 
required  distance.  If,  by  reason  of  the  physical  signs,  a  point  for 
puncture  is  selected  lower  than  the  angle  of  the  scapula — say,  in 
the  ninth  or  tenth  intercostal  space — the  point  of  the  needle 
should  be  directed  obliquely  upward  in  order  to  avoid  injury  to 
the  diaphragm.  In  any  event  the  point  of  the  needle  should 
first  enter  the  chest  close  to  the  upper  edge  of  a  rib  in  order  to 
avoid  the  intercostal  artery.  If  it  is  desired  to  remove  all  of  the 
fluid,  this  should  be  done  slowly;  otherwise  circulatory  disturb- 
ances may  ensue  as  a  result  of  the  rapid  relief  of  pressure  on  the 
heart  and  large  vessels.  These  precautions  are  particularly 
necessary  in  left-sided  effusions. 

Complications  Arising  From  Opening  the  Pleural  Cavity. — 
Should  the  pleural  cavity  be  accidentally  opened,  the  aperture 
is  immediately  closed  with  the  finger,  and  later  by  suturing  or  a 
gauze  packing.  The  entrance  of  small  quantities  of  air  produces 
no  disturbances  of  respiration,  and  the  air  is  quickly  absorbed. 
The  entrance  of  a  large  amount  of  air  produces  symptoms  of 


OPERATIONS    UPON    THE    THORAX  433 

acute  'pneumothorax.  Such  an  accident  may  result  disastrously 
in  a  few  minutes.  The  opening  must  be  immediately  plugged, 
artificial  respiration  by  the  Meltzer  method  begun,  cardiac  and 
respiratory  stimulants  given,  and  oxygen  administered.  It  is 
likely  that  the  withdrawal  of  the  air  by  an  aspirating  apparatus 
would  be  beneficial.  If  the  patient  survives  the  first  shock  of 
the  entrance  of  a  large  amount  of  air,  and  no  infection  has 
occurred,  recovery  may  prove  uneventful,  providing  the  open- 
ing can  be  hermetically  sutured.  If  the  opening  is  too  large  to 
close  by  suture,  the  wound  may  be  filled  with  gauze,  in  which 
event  the  subsequent  treatment  will  be  as  for  empyema.  Should 
pus  enter  the  pleural  sac,  as  for  example  during  an  operation  for 
tuberculous  disease  of  a  rib  with  abscess  formation,  pleuritis  is 
likely  to  follow.  The  characteristic  hissing  should  be  watched 
for  whenever  a  wound  is  dressed  which  is  in  proximity  to  the 
pleura.  Heating  Process  in  Wounds  of  the  Pleura. — Small 
wounds  close  in  a  few  days.  Larger  tears  heal  by  agglutina- 
tion of  the  visceral  and  parietal  pleurae. 

Serous  Pleuritis. — Should  this  complication  occur,  para- 
centesis should  be  practised.  The  relief  experienced  will  be 
immediate.  If  a  small  amount  of  fluid  remains,  this  is  quickly 
absorbed.  The  fluid  may  reaccumulate  to  a  slight  extent, 
as  shown  by  the  line  of  dulness  the  day  following  the  para- 
centesis. This  is  only  temporary.  In  most  cases  a  single  aspira- 
tion is  sufficient  for  a  cure.  In  a  few  cases  two  or  more  will  be 
necessary. 

Suppurative  Pleuritis.  Empyema  Thoracic. — The  after-treat- 
ment does  not  differ  when  simple  incision  is  performed,  or  when 
one  or  more  ribs  are  resected.  Drainage. — It  is  presumed  that 
the  operation  has  completely  emptied  the  pleural  cavity  of  pus 
and  masses  of  fibrous  exudate.  In  very  recent  cases  in  children 
in  which  the  lung  completely  expands  at  the  time  of  operation, 
simply  packing  the  wound  with  gauze  may  be  sufficient.  Such 
cases  are  rare.  In  most  cases  it  will  be  necessary  to  employ  a 
rubber  drainage  tube.  There  are  many  ways  of  arranging  this 
tube.  The  tube  may  be  slender,  fenestrated,  curved  on  itself, 
the  coils  held  in  place  by  strands  of  catgut,  thus  forming 
a  mat  which  rests  on  the  floor  of  the  cavity,  the  proximal  end 

28 


434  OPERATIXG    ROOM    AXD    THE    PATIENT 

of  the  tube  emerging  from  the  openmg;  or  it  may  be  short  and 
thick  and  simply  serve  to  preserve  an  opening  in  the  chest  wall, 
through  which  the  secretions  may  escape.  Various  other  methods 
of  placing  the  tube  are  used,  but  the  above  represent  the  two 
extremes.  Care  must  be  taken  that  the  tube  does  not  press  upon 
the  lung,  or  injury  may  result.  The  tube  may  be  retained  in 
place  hj  passing  a  large  safety-pin  through  its  walls,  but  not 
through  its  lumen,  close  to  the  chest  wall,  and  a  piece  of  tape 
passed  through  the  pin  and  fastened  around  the  chest  or  to  a 
piece  of  adhesive  plaster.  The  tube  at  its  entrance  into  the  chest 
wall  is  surrounded  with  gauze.  If  the  jms  he  thin  and  no  fibrous 
deposits  are  present,  the  coiled  tube  or  a  tube  which  lies  at  the 
bottom  of  the  cavity  during  the  ordinary  movements  of  the  pa- 
tient may  be  employed.  The  dressing  around  the  tube  is  fastened 
in  place  by  a  chest  binder,  through  which  an  opening  has  been 
l^rovided  for  the  emergence  of  the  tube.  To  the  chest  tube  a 
long  tube  is  connected,  the  distal  end  of  which  is  submerged  in  a 
bottle  of  bichlorid  of  mercury  (1-1000)  placed  beside  the  bed. 
The  respiratory  movements  of  the  affected  lung  or  its  fellow  will 
cause  the  antiseptic  solution  to  rise  and  fall  in  the  tube,  and  this 
will  aid  in  causing  the  pus  to  flow  down  the  tube  and  into  the 
solution,  thus  keeping  the  cavity  thoroughly  drained,  and  by 
keeping  the  chest  dressing  clean,  allow  of  ready  closure  of  the 
thoracic  wound  around  the  tube.  The  catgut  on  the  coiled  tube 
loosens  in  from  three  to  six  days  and  the  tube  may  then  be  with- 
draw^n  by  gentle  traction,  and  if  the  discharge  is  profuse,  be  re- 
placed by  a  short  drainage  tube.  If  the  coiled  tube  has  been 
properly  arranged,  the  chest  dressing  will  not  need  changing 
until  the  tube  is  changed. 

If  the  pus  he  thick  or  if  fihrous  deposits  are  present,  a  thick- 
walled  tube  of  large  calibre  will  be  used,  which  will  project  but 
slightly  into  the  cavity.  Such  a  tube  may  be  sewn  into  the  wound 
by  stitches  including  its  wall,  but  not  encroaching  on  its  lumen,  or 
may  be  fastened  by  tapes  as  described  above.  A  copious  gauze 
dressing  is  applied  to  receive  the  discharges.  This  dressing  should 
be  changed  as  frequently  as  soiled,  and  each  renewal  of  dressing 
should  be  done  ivith  aseptic  precautions.  This  large  tube  may  be 
connected  with  a  bottle  as  described  above.     Position  of  the 


OPERATIONS    UPON    THE    THORAX  435 

Patient. — Such  patients  are  not  allowed  to  sit  up  for  at  least 
twenty-four  hours.  Indeed,  they  should  resume  the  sitting 
position  by  degrees.  These  patients  are,  as  a  rule,  emaciated 
by  long  illness.  Their  respiratory  and  circulatory  apparatus 
have  experienced  a  shock,  and  a  sudden  change  in  position  may 
produce  a  severe  and  even  fatal  syncope.  Even  during  the  first 
few  hours  the  head  may  be  supported  by  a  pillow.  After  the 
affect  of  the  anesthetic  has  passed  off,  the  head  and  trunk  may 
be  gradually  elevated  to  ensure  more  efficient  drainage  by  caus- 
ing deeper  respirations.  The  patient  is  encouraged  to  lie  on  the 
diseased  side  as  much  as  possible  and  to  assume  such  positions 
as  will  provide  the  most  efficient  drainage,  in  order  to  prevent 
stagnation  of  secretions.  Significance  of  Fever. — Rise  of  tempera- 
ture, if  it  occurs  early  in  the  first  forty-eight  hours  following  the 
operation,  may  be  due  to  the  supervention  of  pneumonia  or  the 
extension  of  latent  or  subsiding  pneumonia.  The  history  would 
lead  us  to  expect  such  a  complication.  If  pulmonary  tubercu- 
losis existed  prior  to  the  operation,  an  acute  pneumonic  process 
may  be  grafted  on  the  already  existing  chronic  one.  By  far  the 
most  common  cause  of  fever,  however,  will  be  stagnation  of  the 
secretions  or  the  presence  of  an  undrained  sacculation.  This  is 
to  be  avoided  as  outlined  above.  If,  however,  the  thick  pus 
refuses  to  flow  from  the  tube,  it  will  be  necessary  to  employ 
irrigation  of  the  cavity.  An  empyema  should  be  kept  as  fresh 
and  clean  as  an  abscess  occurring  elsewhere.  Well-placed  drain- 
age and  a  favorable  position  of  the  patient  will  usually  accomplish 
this.  Irrigation  is  only  to  be  used  in  cases  which  refuse  to  drain 
by  the  ordinary  methods.  The  temperature  of  the  irrigating 
fluid  should  be  100°  F.  to  avoid  shock,  and  a  sufficient  amount 
of  the  fluid,  at  least  one  quart,  employed  to  thoroughly  cleanse 
the  cavity.  Solutions  of  carbolic  or  bichlorid  of  mercury  are  to 
be  avoided.  Normal  saline  solution  or  boro-salicylic  acid  solu- 
tion may  be  employed.  If  masses  of  fibrinous  exudate  persist, 
they  are  to  be  removed  by  long-handled  blunt  forceps.  Their 
disintegration  may  be  facilitated  by  the  use  of  small  quantities 
of  peroxid  of  hydrogen  injected  through  the  tube.  If  the  fever 
is  due  to  an  undrained  sacculation  this  may  be  opened  by  the 


436  OPERATIXC4    ROOM    AXD    THE    PATIEXT 

finger  through  the   wound,  or  if  this   is   impractical   a   second 
external  opening  may  be  made. 

In  case  seyeral  sacculations  or  cavities  are  present  these  can 
be  drained  through  separate  tubes,  or  may  be  converted  into  one 
cavit3\  If  drainage  is  proi3erly  provided  for  and  if  no  complica- 
tions such  as  pneumonia  supervene,  or  if  the  case  is  not  a  tuber- 
culous one,  the  temperature  soon  reaches  normal.  The  amount 
of  shock  will  depend  upon  the  previous  condition  of  the  patient, 
the  acuteness  of  the  process,  and  somewhat  upon  the  rapidity 
with  which  the  cavity  has  been  emptied.  It  will  be  greater  in 
those  cases  in  which  irrigation  has  been  used.  It  is  to  be  looked 
for  in  all  cases  and  combated  by  the  usual  means.  Hemorrhage 
may  occasionally  occur  from  an  improperly  ligated  intercostal 
artery  in  cases  in  which  this  has  been  unfortunately  injured; 
rarely  from  the  cavity  itself  unless  extensive  adhesions  have  been 
disturbed,  either  by  manipulation  or  by  too  rapid  emptying  of 
the  cavity.  In  the  former  case  the  bleeding  vessel  must  be 
sought  for  and  ligatured;  in  the  latter,  if  excessive,  the  tem- 
joorary  closure  of  the  opening  in  the  chest  wall  will  control  the 
hemorrhage.  This  is  affected  by  strapping  a  compress  over  the 
opening. 

Emphysema  of  the  Subcutaneous  Tissues  may  occur  if  the  dress- 
ing or  tube  becomes  disarranged  in  such  a  manner  as  to  allow' 
air  to  be  drawn  into  the  cavity  and  yet  interfere  with  its  free 
exit.  The  air  is  then  forced  mto  the  wound  and  emphysema 
results.  The  treatment  is  to  revise  the  dressing.  No  attempt 
should  be  made  to  force  the  air  out  of  the  tissues.  Its  absorption 
is  usually  prompt. 

Infection  of  the  cellular  tissue  rarely  occurs  as  wound  drainage 
is  free.  It  is  treated  by  multiple  incisions.  Gravitation  abscess 
occasionally  occurs,  necessitating  incision  at  the  most  dependant 
point  of  the  infection. 

Complicating  Empyema  of  the  opposite  side  rarely  occurs.  It 
is  best  treated  by  repeated  aspiration  with  injection  of  10  per 
cent,  formalin  glycerin  solution  until  the  expansion  of  the  lung 
on  the  operated  side  is  sufficient  to  permit  of  drainage  of 
the  complicating  empyema.  Whenever  possible  the  operation 
should  be  done,  and  the  patient  kept,  under  negative  pressure. 


OPERATIONS    UPON    THE    THORAX  437 

Lung  Gymnastics. — The  patient  is  to  be  gotten  out  of  bed  and 
in  the  open  air  as  soon  as  he  is  able  to  move  about  and  calisthenic 
exercises  calculated  to  expand  the  chest  enforced.  He  is  in- 
structed in  the  use  of  water  bottles  in  order  to  expand  the  lung 
as  quickly  as  possible.  Their  use  may  be  begun  on  the  second 
day.  The  longer  expansion  of  the  lung  is  neglected  the 
more  difficult  it  will  become,  as  the  adhesions  will  become  more 
dense.  Expansion  of  the  lung  and  free  drainage  is  facilitated  by 
the  use  of  a  vacuum  cup  applied  to  the  sinus  or  Bryant^ s^  method 
of  aspiration  combined  ivith  drainage  may  be  employed. 


Fig.  192. — Bryant's  aspiration  and  drainage  apparatus,  a.  Hollow 
rubber  cushion  (the  author  now  uses  wet  rubber  tissue  as  the  cushion  was 
not  satisfactory  in  all  cases) ;  b,  rubber  bag;  c,  stop-cock;  d,  glass  observation- 
tube;  €,  drainage  tube. 

This  method  combines  aspiration  for  the  purpose  of  expansion 
of  the  lung  and  drainage  by  means  of  a  special  apparatus  (Fig. 
192).  The  drainage  tube  is  placed  into  the  cavity  for  the  proper 
distance  and  the  cushion  is  placed  in  contact  with  the  wall  of  the 
thorax  in  such  a  manner  as  to  cover  the  area  surrounding  the 
opening  into  the  pleural  cavity.  The  nozzle  of  an  ordinary  6-oz. 
rubber  syringe  is  then  inserted  into  the  distal  end  of  the  appara- 
tus, the  cavity  emptied  of  all  liquid,  and  sufficient  air  exhausted 

1  Operative  Surgery,  Bryant,  1901,  vol.  ii,  p.  1026. 


438  OPERATIXG    EOOM    AXD    THE    PATIEXT 

to  cause  the  rubber  cushion  to  fit  closely  enough  to  the  chest  wall 
to  prevent  the  passage  of  aii"  beneath  it.  The  stop-cock  is  then 
closed,  the  syringe  removed  and  the  nozzle  of  the  rubber  bag  with 
the  ail'  exhausted  inserted  into  the  open  end  of  the  tube.  The 
stop-cock  is  then  opened  thus  establishing  aspiration  which  will 
be  maintained  so  long  as  the  bag  is  expanding.  A  suitable  reten- 
tive dressing  is  then  applied.  When  the  rubber  bag  is  nearly 
distended  the  stop-cock  is  again  closed,  the  bag  emptied,  cleansed, 
collapsed,  reapplied  and  the  stop-cock  opened.  The  degree  of 
distention  of  the  bag  should  be  frec^aently  observed  so  that  this 
procedure  can  be  repeated  frec^uently  enough  to  obviate  inter- 
ruption of  the  asphation.  Continuous  and  mild  aspiration  is 
quite  as  effective  as  more  vigorous.  The  patient  can  be  in- 
structed in  the  procedure  and  can  go  about  with  the  apparatus 
in  place  without  attracting  special  attention.  The  rubber  vac- 
uum cup  has  not  proved  thoroughly  satisfactory.  Dr.  Bryant 
now  uses  wet  gutta-percha  tissue  to  surround  the  tube  and 
cover  the  wound  opening  to  prevent  leakage. 

Duration  of  Healing.- — In  acute  cases  the  lung  expands  readily 
as  a  nile,  and  the  cavity  quickly  closes.  In  babies  the  process 
may  take  from  fourteen  to  twenty-one  days.  The  longer  the 
duration  of  the  empyema  the  longer  vriR  the  cavity  persist. 
In  long-standing  cases,  as  in  those  in  which  tuberculous  infection 
is  superadded,  an  extremely  long  after-course  is  to  be  expected. 
In  such  cases  means  (decortication  or  other  plastic  operation) 
other  than  gymnastic  must  be  considered  with  the  view  of  ob- 
literating the  cavity. 

Secondary  Scoliosis. — As  a  result  of  the  approximation  of  the 
ribs  of  tha  affected  side,  hj  reason  of  the  lack  of  necessity  for  the 
muscular  apparatus  of  that  side  to  take  part  in  the  respirator}- 
act,  the  dorsal  portion  of  the  spine  becomes  scoliosed,  with  the 
concavity  of  the  deformity  toward  the  affected  side.  Com- 
pensatory curves  in  the  cervical  and  lumbar  region  will  follow 
in  time.  These  deformities  will  disappear  in  case  the  lung  can 
be  subsequently  made  to  expand.  This  is  best  accomplished 
by  decortication  of  the  lung  (George  Ryerson  Fowler). 

Fistula  following  Efnpyema. — This  is  frequently  met  with 
in  those  cases  in  which  a  system  of  lung  gymnastics  has  not  been 


OPERATIONS    UPON    THE    THORAX  439 

thoroughly  carried  out,  in  those  cases  in  which  the  empyema 
has  been  present  for  a  long  time  and  many  adhesions  have 
formed,  and  in  tuberculous  cases.  Fistulse  may  also  be  caused 
by  a  retained  drainage  tube.  Here,  as  in  operations  upon  the 
ribs  alone,  necrosis  may  cause  the  fistula  to  persist.  Should  a 
fistula  persist  eight  weeks  after  an  operation  for  empyema,  its 
cause  must  be  ascertained.  A  thorough  examination  of  the 
patient  will  reveal  any  tuberculous  disease.  The  general  con- 
dition is  to  be  improved  as  much  as  possible,  lung  gymnastics 
are  to  be  insisted  upon,  and  a  vigorous  cleansing  and  disinfection 
of  the  cavity,  with  breaking  up  of  adhesions  with  the  finger  or 
blunt  curette  done.  Should  the  cavity  still  persist,  several 
courses  are  open  to  us  with  the  view  of  obliterating  the  cavity. 
Either  the  chest  wall  can  be  sunk  in  by  an  extensive  resection  of 
the  rib  overlying  it  (Estlander's  or  Schede's  operations),  or  the 
affected  pleura  can  be  resected,  removing  with  it  the  dense 
adhesions,  and  thus  freeing  the  lung  (Fowler),  or  a  combination 
of  these  methods  may  be  employed.  If  a  retained  drainage 
tube  is  the  cause,  removal  of  this  will  usually  suffice  for  a  cure. 
Operative  methods  should  not  be  resorted  to  until  it  is  seen 
that  the  cavity  will  not  close  by  nature's  aid  alone.  Nature 
tends  to  close  such  cavities  by  expansion  of  the  lung  on  the 
diseased  side,  by  expansion  of  the  opposite  lung,  by  the  increased 
use  of  the  diaphragm  upon  that  side  and  by  a  narrowing  of  the 
intercostal  spaces  by  a  gradually  encroaching  of  the  ribs  until 
finally  they  may  even  overlap.  Not  all  cases  can  be  cured  even 
by  extensive  operations,  and  in  obstinate  cases  several  operations 
may  be  necessary.  These  cases  make  poor  subjects  for  operation 
by  reason  of  the  long  period  of  suppuration  and  the  possible 
tuberculous  diathesis.  Radiography  is  useful  in  determining 
the  size  of  the  cavity  or  the  presence  of  foreign  bodies. 

Thoracoplasty  (Estlander,  Schede) ;  Decortication  of  Lung 
(Fowler). — The  after-treatment  of  the  operation  consists  in  a 
primary  abundant  dressing  of  sterile  gauze.  If  a  small  cavity 
still  persists,  a  drainage  tube  may  be  employed  or  the  cavity 
may  be  drained  by  gauze.  Serous  discharge  is  free  and  frequent 
change  of  dressing  necessary.  The  remainder  of  the  after- 
treatment  is  carried  out  along  the  lines  already  outlined. 


440  OPERATING    ROOM    AND    THE    PATIENT 

Operations  involving  the  Lung. — The  lung  may  be  invaded 
in  cases  of  abscess,  gangrene,  tumors,  or  tuberculous  cavities.  In 
whichever  event  an  important  step  consists  in  preliminarily- 
suturing  the  visceral  to  the  parietal  pleura  if  adhesion  is  not 
already  present.  This  serves  not  only  to  steady  the  lung,  but 
more  important  still  tends  to  prevent  infection  of  the  pleural 
sac.  Septic  pneumonia  gives  these  cases  a  high  mortality.  The 
wound  is  treated  as  an  empyema,  with  the  exception  that  it 
should  not  be  irrigated,  in  which  case  the  lung  might  be  flooded 
through  a  bronchus  opening  into  the  wound  cavity.  Should 
pleuritis  complicate  or  supervene,  it  is  to  be  treated  on  the 
principles  already  laid  down.  Subcutaneous  emph-gsema  may 
develop. 

General  Rules. — Absolute  rest  in  the  recumbent  position  with 
slight  elevation  of  the  chest  aids  spontaneous  arrest  of  hemor- 
rhage and  tends  to  prevent  complications.  If  hemorrhage  occurs 
the  wound  is  tightly  repacked  or  if  the  cavity  is  small  it  is  sufficient 
to  seal  the  external  opening  in  the  chest.  Wounded  lungs  not 
sutured  to  the  chest  wall  will  bleed  until  retraction  of  the  lung 
is  complete.  Attempts  to  fix  the  chest  wall  with  a  view  of  con- 
trolling the  hemorrhage  are  useless  on  account  of  the  compen- 
satory action  of  the  diaphragm.  The  chest  wall,  however, 
should  be  fixed  if  painful  wounds  of  the  wall  are  present. 

The  odor  in  abscess  cases  is  very  offensive.  It  is  best  con- 
trolled by  very  frequent  change  of  dressing.  Such  wounds  heal 
very  slowly  and  frequently  require  plastic  operation  or  thermo- 
cauterization  for  the  cure  of  bronchial  fistula. 

Operations  upon  the  Heart. — Bleeding  is  favored  by  anything 
which  increases  the  rapidity  of  the  heart  action  or  by  anything 
which  strengthens  the  force  of  each  pulsation,  therefore  the 
patient  is  to  be  kept  absolutely  at  rest,  both  mental  and  physical, 
and  stimulation  if  given  at  all,  should  be  very  cautiously  admin- 
istered. The  patient  is  kept  free  from  all  excitement  in  a  com- 
fortable recumbent  position  in  an  absolutely  quiet  and  partially 
darkened  room.  The  patient  is  reassured  as  to  his  condition. 
Morphin  is  given  hypodermically  to  relieve  the  pain  and  ensure 
quiet.     Ice  to  the  precordial  region  tends  to  relieve  pain. 

Complications. — Primary  shock  occurs  on  the  receipt  of  the 


OPERATIONS    UPON    THE    THORAX  441 

injury  or  in  set  operations  at  the  time  of  making  the  cardiac 
manipulations  and  is  immediately  fatal. 

Hemorrhage  is  the  most  frequent  cause  of  death.  Severe 
hemorrhage  may  be  delayed  for  some  hours  after  the  operation. 

Secondary  carditis  follows  laceration  or  contusion. 

Endocarditis  is  a  frequent  complication  and  is  often  associated 
with  carditis.     It  is  due  to  traumatism. 

Pericarditis  is  the  most  frequent  complication.  It  may  be 
circumscribed  or  general.  If  accompanied  by  effusion,  aspiration 
is  indicated  and  if  the  fluid  recurs,  drainage. 

Paracentesis  of  the  Pericardium. — Usually  the  heart,  in  cases 
of  pericardial  effusion,  is  crowded  well  back  and  out  of  the  way, 
while  the  pericardium  presses  forward,  producing  bulging  of 
the  intercostal  spaces.  By  percussion  the  area  of  dulness  is 
readily  mapped  out.  The  most  favorable  point  for  puncture 
is  just  above  the  upper  edge  of  the  sixth  costal  cartilage,  near  the 
left  lateral  edge  of  the  sternum.  The  exploring  needle  should 
be  introduced  carefully  and  slowly  away  from  the  apex.  As 
soon  as  fluid  ceases  to  flow,  the  needle  should  be  withdrawn,  and 
the  entrance  of  air  avoided. 

Pleuritis  either  circumscribed  or  general  is  a  frequent  compli- 
cation whether  the  pleura  has  been  directly  injured  or  not. 
It  often  results  in  empyema. 

Pneumonitis  of  varying  degree  may  occur  whether  the  lung- 
has  been  injured  or  not. 

E7nbolism  is  a  frequent  cause  of  death  if  the  wound  involved 
the  cavity  of  the  heart. 

Entrance  of  air  may  cause  immediate  or  subsequent  death. 
Its  entrance  following  operation  is  caused  by  failure  of  wound 
union  through  loosening  or  too  early  absorption  of  the  sutures. 

Abscess  may  occur  in  the  heart  wall,  in  the  pericardium  or 
pleura  or  in  the  mediastinum.     Free  drainage  is  indicated. 

Aneurysm  in  the  heart  cicatrix  has  been  observed. 

Asthenia  may  be  the  result  from  any  of  these  complications. 


442  OPERATIXG    ROOM    AND    THE    PATIENT 


CH.\PTER  XVI. 
OPERATIONS  UPON  THE  ABDOMEN. 

General  Considerations. — The  post-operative  treatment  in  all 
acute  abdominal  conditions  and  in  mam-  chronic  cases  begins 
■^dien  the  patient  is  first  taken  ill  and  consists  in  early  recogni- 
tion of  the  possible  need  of  surgical  intervention  and  the  intelli- 
gent pre-operative  treatment  of  the  condition.  This  is  par- 
ticularly true  in  perforations  and  acute  infective  processes. 
The  so-called  operative  mortality  can  be  very  materially  lowered 
by  the  observation  by  the  medical  attendant  of  a  few  simple 
rules.  In  acute  conditions  of  the  abdomen  all  feeding  by  stomach 
is  contraindicated.  Xothing,  not  even  water  should  be  given, 
for  the  reason  that  the  ingestion  of  an}i;hing  in  the  stomach 
results  in  peristalsis  with  its  accompanying  spread  of  whatever 
infection  is  present.  The  tissues  must  not,  however,  be  deprived 
of  water  or  the  possible  operative  procedure  will  have  a  disastrous 
effect  upon  the  general  metabolism.  Fluid  is  administered  by 
rectum  either  by  slow  frequently  repeated  enemata  or  by  Murphy 
proctoclysis,  or  in  urgent  cases  by  hypodermoclysis.  Morphin 
must  be  withheld  until  a  diagnosis  is  reached.  If  these  rules 
are  followed  out  an  earlier  diagnosis  is  possible,  and  if  a  surgical 
operation  is  indicated  the  patient  is  in  the  best  possible  con- 
dition for  it. 

The  after-treatment  of  operations  on  the  abdomen  differs 
but  little  from  the  after-treatment  of  operations  in  general. 
The  difference  depends  upon  two  or  three  underhdng  principles 
which,  if  understood,  simplify  the  after-treatment  to  a  great 
extent.  Removal  of  a  patient  from  the  operating  table  to  the 
bed  is  done  with  the  usual  care  that  no  additional  injury  be 
inflicted  or  strain  put  upon  the  operated  part.  The  treatment 
of  shock  is  as  for  other  operations  and  the  treatment  of  the  wound 
itself  is  as  for  wounds  of  a  similar  nature  in  other  parts  of  the 
body.  It  is  to  be  noted,  however,  that  kidney  complications 
and  lung  complications  occur  more  frequently  after  laparotomy 


OPERATIONS    UPON    THE    ABDOMEN  443 

than  after  operations  on  other  parts  of  the  body,  and  that  shock 
is  a  more  frequent  complication.  For  these  reasons  it  is  best 
to  give  saline  by  rectum  following  all  laparotomies.  Either 
the  repeated  slow  saline  enemata  or  Murphy  proctoclysis  may 
be  used. 

Our  knowledge  of  these  cases  has  so  increased  of  late  years 
that  these  three  main  complications,  shock,  nephritis  and 
pneumonia,  are  rarely  met  with.  With  care  in  the  preparation 
of  patients  and  with  the  anesthesia,  and  with  proper  technic 
and  speediness  in  operating,  they  will  become  less  and  less 
common.  In  former  years  the  complication  of  intraabdominal 
hemorrhage  and  of  post-operative  intestinal  obstruction  and 
peritonitis  in  various  forms  were  the  commoner  complications. 
Nowadays,  due  to  better  technic  at  the  operation  and  to  a  better 
regard  in  the  treatment  of  tissues  these  complications  are  seldom 
met  with. 

The  lesser  complications  of  vomiting  and  distention  are  still 
frequent,  but  not  so  common  as  formerly.  Careful  anesthesia 
precludes  the  one  and  an  efficient  pre-operative  preparation 
excludes  the  second. 

Given  a  clean  laparotomy  in  which  no  operation  has  been 
done  upon  the  intestinal  canal  and  in  which  the  abdominal 
wound  has  been  properly  made  and  sutured,  the  after-course 
should  be  as  uneventful  as  an  operation  upon  any  other  part 
of  the  body.  Irrespective  of  what  operation  has  been  done 
intraabdominally  there  are  usually  no  complications.  The  post- 
operative treatment  is  the  same  as  in  operations  elsewhere.  The 
patient  is  kept  quiet  for  twenty-four  hours  or  until  the  anesthetic 
nausea  has  ceased  and  may  then  sit  up  or  be  propped  up  in  bed. 
Wound  quiet  is  maintained  by  the  use  of  a  tight-fitting  abdominal 
bandage  of  adhesive  plaster  after  the  method  of  Boldt,  reenforced 
by  a  snug-fitting  abdominal  binder.  The  intraabdominal 
pressure  acts  with  the  extraabdominal  support  to  maintain 
rest  of  the  wound.  Abdominal  tension  is  relieved  by  placing 
pillows  beneath  the  knees.  The  period  of  rest  in  bed  depends 
almost  entirely  upon  the  patient's  general  condition.  For  in- 
stance, if  the  patient  has  lost  a  large  amount  of  blood  at  the 
operation,   or  is   anemic  from  long   continued   illness,   general 


444  OPERATIXG    ROOM    AXD    THE    PATIENT 

conditions  which  would  affect  wound  healing,  it  would  be  best  to 
keep  the  patient  quiet  in  bed  until  sach  a  time  as  the  blood 
examination  showed  rapid  improvement  in  the  blood  condition. 
It  is  well  known  that  wounds  in  anemic  persons  do  not  heal 
with  the  rapidity  of  wounds  in  robust  persons.  Such  a  wound 
would  need  support  and  rest  for  a  longer  time.  Barring  this 
complication,  however,  there  is  no  reason  why  such  patients 
should  not  be  allowed  up  in  bed  at  the  end  of  twenty-four  hours, 
out  of  bed  in  a  chair  in  two  or  three  or  four  days  and  be  allowed 
to  take  a  few  steps  on  the  following  day.  Reiss  of  Chicago  who 
originated  the  "ambulatory  treatment"  of  laparotomy  gets  his 
patients  up  even  earlier.  The  size  of  the  wound  does  not  con- 
traindicate  this  providing  the  wound  has  been  suitably  made  and 
sutured  and  properly  supported  to  ensure  rest.  In  hundreds  of 
laparotomies  treated  in  this  manner  I  have  not  had  one  untoward 
symptom.  In  fact  convalescence  has  been  hastened  and  wound 
healing  made  more  rapid.  If  infection  occurs  it  will  occur  irre- 
spective of  the  position  of  the  patient.  Should  infection  occur 
it  is  treated  on  general  wound  principles  and  the  patient  is  kept 
in  bed  until  the  infection  has  cleared  up.  When  the  wound  has 
reached  the  condition  when  it  can  be  strapped  the  ambulatory 
treatment  can  again  be  initiated. 

Diet  in  this  class  of  cases  should  be  brought,  as  rapidly  as  the 
condition  of  the  stomach  will  permit,  to  the  normal  diet.  For 
the  first  twenty-four  hours  the  diet  is  as  in  all  post-anesthesia 
cases;  following  this  the  diet  is  rapidly  increased.  It  is  to  be 
remembered  that  the  stomach  is  in  a  weakened  condition  follow- 
ing the  use  of  any  general  anesthetic  and  that  food  must  not 
be  forced  at  first.  Nor  should  the  ingestion  of  large  quantities 
of  fluid  at  one  time  or  at  frecfuent  intervals  be  allowed  as  this  is 
apt  to  result  in  a  dilatation  of  the  stomach. 

Bowels. — The  bowels  should  be  moved  daily  for  the  first  few 
days  by  a  copious  enema  of  soapsuds  and  water.  After  the  first 
few  days  some  form  of  pill  may  be  given  preferably  containing 
aloin,  belladonna  and  strychnin  in  just  sufficient  doses  to  pro- 
duce evacuation  w'ithout  purgation.  Distention  is  not  apt  to 
occur  in  these  cases  except  in  debilitated  subjects  or  in  elderly 
people,  or  in  cases  in  which  very  large  intraabdominal  growths 


OPERATIONS    UPON    THE    ABDOMEN  445 

have  been  removed.  In  such  cases  distention  is  carefully  watched 
for  and  its  relief  by  enemata  initiated  before  great  distention 
has  occurred.  In  the  case  of  large  growths  a  preventive  consists 
in  filling  the  abdomen  with  saline  after  removal  of  the  growth. 
In  this  and  in  the  other  two  cases  mentioned  above  the  distention 
is  due  to  the  paretic  condition  of  the  intestine.  Of  all  the  drugs 
which  act  in  this  regard  atropin  is  the  best.  Atropin  sulphate 
gr.  1/50  given  hypodermically  will  aid  in  toning  up  the  afferent 
intestinal  nerve  impulses.  Opium  or  any  of  its  derivatives  should 
be  avoided  in  these  cases.  If  the  distention  does  not  subside 
following  ah  ordinary  enema  of  soapsuds  and  water,  an  efficient 
enema  is  one  quart  of  warm  water  in  which  one  ounce  of  alum 
has- been  dissolved.  This  enema  will  succeed  in  bringing  away 
the  gas  unless  paresis  is  complete  or  unless  a  mechanical  obstruc- 
tion exists. 

Pain. — Pain  in  the  first  few  hours  following  the  operation  is 
due  to  distention  or  to  the  traumatism  inflicted  at  the  operation 
to  the  wound  itself  or  to  the  abdominal  muscles  through  retrac- 
tion. In  the  former  event  the  pain  is  relieved  by  enema;  in 
the  later  event  one  dose  of  one  quarter  of  a  grain  of  morphin  is 
administered  hypodermically.  One  does  not  like  to  use 
morphin  because  of  its  after-effect  in  favoring  intestinal  dis- 
tention. If,  however,  the  enema  fails  to  relieve  the  pain  one 
quarter  of  a  grain  of  morphin  may  be  given.  This  dose  should 
not  be  repeated  except  in  rare  instances. 

Operations  upon  the  gastrointestinal  canal  should  be  treated 
as  above  except  as  regards  diet  and  catharsis.  The  after-treat- 
ment of  these  operations  will  be  taken  up  in  detail  later.  In 
general  it  may  be  said  that  following  intestinal  resection  it  is  best 
to  give  repeated  small  doses  of  magnesium  sulphate,  one  dram  of 
a  saturated  solution  every  hour  or  two  in  order  that  the  contents 
of  the  intestinal  canal  may  be  kept  liquid  and  that  impaction  at 
the  site  of  the  Murphy  button  or  suture  line  may  not  occur.  Ac- 
tive cathartics  should  not  be  administered  before  the  ninth  day 
at  which  time  intestinal  wound  healing  is  complete.  Intestinal 
wounds  are  supported  for  the  first  three  days  by  sutures;  from 
the  third  to  the  fifth  day  which  is  the  weakest  time,  the  sutures 
loosen  somewhat  and  the  parts  are  held  together  by  weak  union; 


446  OPERATING    ROOM    AND    THE    PATIENT 

from  the  fifth  day  on  the  union  is  firmer  until  by  the  ninth  day 
it  is  complete.  During  this  period  no  cathartics  should  be  ad- 
ministered which  will  act  in  a  forceful  manner  on  the  musculature 
of  the  intestine.  Following  appendectomy  on  account  of  the 
nature  of  the  intestinal  wound  this  rule  is  not  so  important;  it 
is  a  good  plan,  however,  to  move  the  bowels  by  enemata  for  the 
first  ten  days  even  in  these  cases.  The  diet  should  not  be  forced 
in  intestinal  resection  cases  but  the  patient  should  be  kept  on 
fluid  and  farinaceous  diet  until  the  ninth  day  when  intestinal 
wound  healing  is  complete. 

Posture  in  Operations  upon  the  Upper  Abdomen. — Following  all 
operations  upon  the  upper  abdomen,  if  the  patient  is  placed  in 
the  semi-sitting  posture  or  in  the  elevated  head  and  trunk  posture 
a  smoother  after-course  will  be  noted  than  if  the  patient  is  kept 
fiat.  There  is  distinctly  less  reaction  following  the  operation, 
the  stomach  emptying  itself  more  easily  into  the  intestine, 
breathing  is  easier,  pulmonary  complications  are  not  as  fre- 
quent and  the  patient  is  very  much  more  comfortable. 

Post-operative  Complications  of  Abdominal  Section. — Periton- 
itis may  immediately  follow  the  operation  due  to  failure  in  aseptic 
technic.  Such  a  peritonitis  is  usually  general  from  the  outset. 
A  certain  amount  of  local  peritonitis  comY)lic&tes  practically  every 
operation  in  the  abdominal  cavity.  This  is  a  conservative  process. 
In  simple  cases  without  drainage  it  rarely  gives  enough  symptoms 
to  have  attention  directed  toward  it.  There  may  be  some  pain 
about  the  neighborhood  of  the  operation  but  it  is  hard  to  dis- 
tinguish this  pain  from  the  soreness  of  the  abdominal  wall  pro- 
duced by  the  wound.  In  drainage  cases  this  conservative  perit- 
onitis is  more  marked  and  causes  a  rise  of  temperature  for  the 
first  few  days.  This  is  particularly  noted  in  operations  upon  the 
upper  abdomen  and  calls  for  no  treatment  other  than  raising 
the  head  of  the  bed  to  retard  absorption.  It  may  extend  beyond 
the  field  of  operation  but  still  occupy  a  limited  area.  The  symp- 
toms are  comparatively  mild.  Pain  and  tenderness  are  present; 
within  the  area  of  inflammation  there  is  a  limited  amount  of 
distention.  The  pulse  and  temperature  are  only  moderately 
accelerated.  The  inflammation  usually  subsides  at  the  end  of 
forty-eight  hours. 


OPERATIONS    UPON    THE    ABDOMEN  447 

It  may,  however,  extend  (spreading  peritonitis)  if  the  infection 
is  a  severe  one  and  may  prove  to  be  the  precursor  of  diffuse  septic 
peritonitis. 

If  localized  no  treatment  is  necessary  as  the  process  is  a  con- 
servative one.  If  the  process  is  more  extensive  saline  by  rectum 
is  given  to  eliminate  the  septic  material  and  distention  is  pre- 
vented by  enemas.  These  measures,  together  with  the  elevated 
head  and  trunk  position  to  prevent  the  rapid  absorption  of  infec- 
tive products,  will  usually  suffice.  If,  however,  the  process  has  a 
tendency  to  spread,  feeding  by  stomach  should  be  discontinued 
in  order  to  prevent  peristalsis  with  consequent  spread  of  the 
infection. 

Cryptogenic  peritonitis  after  operations  for  infectious  processes 
in  the  abdomen.  It  occasionally  happens  that  an  intraabdom- 
inal abscess  develops  at  a  point  distant  from  the  original  focus. 
The  secondary  abscess  may  be  on  the  other  side  of  the  abdomen, 
may  be  in  the  pelvis,  under  the  liver  or  in  the  neighborhood  of  the 
kidney.  It  is  always  a  question  whether  such  an  abscess  is  caused 
by  the  direct  extension  of  the  infection,  or  through  the  lymph 
channels  causing  a  secondary  infection.  In  any  event,  some 
time  after  an  operation  for  peritoneal  abscess  the  temperature 
rises  and  symptoms  of  further  infection  are  shown.  An  examina- 
tion of  the  wound  fails  to  disclose  ^ny  cause  therein  for  the  symp- 
toms. A  thorough  examination  of  the  abdomen,  loins  and  rectum 
will  show  signs  of  inflammation  at  a  point  remote  from  the 
original  focus.  Such  abscesses  are  opened  by  the  route  affording 
the  best  drainage.  Pelvic  abscesses  in  females  are  opened  per 
vaginam  and  abscesses  in  the  neighborhood  of  the  kidney, 
through  the  loin.  Those  not  far  distant  from  the  wound  are 
opened  through  the  original  wound. 

Wound  treatment  and  wound  complications  are  the  same  as 
found  in  wounds  elsewhere. 

Infection  of  the  abdominal  wound  may  be  expected  following 
operations  for  acute  infective  processes  in  the  abdomen  such  as 
acute  appendicitis  and  pyosalpingitis.  Such  infections  will  occur 
regularly  if  suitable  preventive  measures  are  not  taken.  Such 
measures  consist  in  the  protection  of  the  wound  surfaces  by  pads 
from  the  infected  organ,  the  handling  of  the  infected  organ  with 


448  OPERATING    ROOM    AXD    THE    PATIENT 

instruments  which  are  discarded  as  soon  as  used,  the  frequent 
rinsing  of  the  gloved  hand  in  an  antiseptic  solution,  and  the 
handling  of  the  wound  with  instruments  other  than  those  used 
in  caring  for  the  infected  organ.  Kocher's  old  adage  of  "noli 
me  tangere"  in  regard  to  the  treatment  of  wounds  in  general 
applies  particularly  here. 

Protecting  the  wound  at  the  expense  of  the  peritoneum  by  draw- 
ing the  peritoneum  up  and  attaching  it  to  the  skin  may  be  done. 
The  rich  lymphatic  system  of  the  peritoneum  is  better  able  to 
care  for  infection  than  the  other  tissues  of  the  abdominal  wound. 

Rupture  of  the  Wound. — This  accident  is  at  the  present  day 
exceedingly  rare.  The  exciting  cause  is  some  muscular  effort 
such  as  occasioned  by  vomiting,  coughing,  straining  at  stool  or 
conscious  or  unconscious  struggling.  The  predisposing  causes 
are  those  conditions  of  the  blood  tending  to  slow  union,  anemia, 
syphilis,  tuberculosis;  conditions  of  the  wound  such  as  infection 
or  secondary  hemorrhage;  lack  of  efficient  technic  in  the  suturing 
or  incomplete  suturing  in  drainage  cases,  imperfect  ligature 
material,  improperly  placed  incisions,  lack  of  proper  wound 
support,  etc.;  and  maniacal  acts. 

Rupture  may  occur  at  any  time  but  in  clean  wounds  is  usually 
met  with  in  the  first  twenty-four  hours;  in  septic  wounds  later. 
The  whole  wound  may  be  involved  or  only  a  part. 

Treatment. — Occurring  in  clean  wounds  the  indications  are  to 
immediately  gently  cleanse  the  extruding  viscera,  replace  them 
and  resuture — ^without  drainage  unless  certain  soiling  has  oc- 
curred through  the  escape  of  some  of  the  bowel  from  beneath  the 
dressing.  Rupture  in  suppurating  wounds  requires  cleansing 
and  replacement  of  the  viscera,  and  graduated  tamponade  of 
the  wound  -with  such  suturing  as  is  necessary  to  support  the 
tamponade.  An  adhesive-plaster  scultetus  is  applied.  Cases 
of  rupture  in  septic  wounds  are  in  addition  treated  as  diffuse 
septic  peritonitis  cases. 

Ventral  Hernia. — This  complication  occurring  as  it  does 
weeks  or  months  following  the  operation  is  largely  preventable. 
It  is  due  to  improperly  placed  incisions,  particularly  incisions 
in  the  linea  alba  in  place  of  through  the  rectus  muscle,  and  in- 
cisions so  placed  as  to  destroy  important  nerves.     Poor  technic 


OPERATIONS  UPON  THE  ABDOMEN  449 

at  the  operation  may  have  allowed  infected  material  to  come  in 
contact  with  the  wound  thus  favoring  infection.  Hernia  may 
also  be  due  to  improper  suturing  of  the  wound,  infection  of  the 
wound,  to  drainage  and  to  conditions  such  as  meteorism  or  lack 
of  sufficient  support  to  the  wound  producing  strain.  Poor  wound 
healing  may  be  due  to  complicating  general  disease. 

Hematemesis. — This  occurs  most  frequently  following  opera- 
tions for  acute  appendicitis.  It  is  rare.  The  blood  comes  from 
minute  ulcerations  of  the  gastric  mucosa  caused  by  plugging 
of  the  gastric  terminal  vessels  with  infectious  emboli  derived 
from  the  infectious  focus  (Van  Cott).  The  symptoms  are  per- 
sistent vomiting  of  dark  brown  or  black  material  consisting  of 
altered  blood.  The  prognosis  is  bad.  The  treatment  consists 
of  repeated  lavage  with  alkaline  solution,  salines  by  rectum  and 
general  supporting  measures. 

Suppurative  Hepatitis. — This  complication  also  most  frequently 
follows  operation  for  acute  appendicitis  though  it  may  occur 
after  any  operation  for  sepsis  involving  the  veins  of  the  mesen- 
tery. Septic  thrombi  in  the  mesenteric  veins  are  displaced  and 
carried  into  the  portal  vein  and  thence  to  the  liver  where  they 
lodge  and  form  septic  foci  with  characteristic  symptoms.  Usu- 
ally these  foci  are  multiple  and  operation  is  unavailing.  Occa- 
sionally; however,  but  one  large  abscess  will  result.  This  latter 
type  presents  a  more  favorable  prognosis 

Purulent  pericarditis  may  follow  hepatic  abscess. 

Purulent  pleuritis  may  occur  in  the  same  way.  It  may  be  the 
only  complication  of  an  acute  appendicitis. 

Subphrenic  abscess  may  complicate. 

Iliac  Phlebitis  with  Thrombosis. — An  edema  of  one  or  both 
of  the  lower  extremities  occurs  as  a  complication  of  apparently 
clean  as  well  as  of  septic  cases.  It  occurs  more  frequently  as  a 
complication  of  acute  appendicitis  where  the  appendix  is  in 
relation  with  the  right  iliac  vein.  Displacement  of  septic 
thrombi  in  this  situation  is  followed  by  pulmonary  thrombosis 
and  septic  pneumonia. 

Portal  phlebitis  has  been  noted. 

Mesenteric  thrombosis  is  a  rare  complication.  It  may  occur 
even  in  clean  cases. 

29 


450  OPERATING    ROOM    AND    THE    PATIENT 

Distention  due  to  Intestinal  Atony. — This  occurs  in  elderly 
patients  with  thin  flaccid  muscles,  particularly  in  those  from 
whom  large  tumors  or  cysts  have  been  removed.  It  occurs 
quickly  following  the  operation  and  is  probably  due  to  sudden 
relief  from  pressure  of  the  growth.  Inspection  shows  a  much 
distended  abdomen,  a  condition  which  later  becomes  extreme 
meteorism.  Occasional  slow  peristaltic  movements  are  seen 
through  the  thin  abdominal  wall.  There  is  no  pain.  The 
abdomen  is  at  first  soft  and  yielding  to  the  hand;  later  extreme 
meteorism  develops  unless  active  measures  are  taken  to  relieve 
the  condition.  If  active  measures  are  not  taken  paresis  results 
and  the  patient  dies. 

Treatment. — ^Preventive  treatment  is  best.  Following  the  re- 
moval of  large  growths  the  peritoneal  cavity  should  be  filled  with 
saline  or  saline  and  oxygen  to  take  the  place  of  the  growth 
and  so  equalize  the  intraabdominal  pressure.  A  tight  binder 
is  applied.  Stimulating  enemata  are  given  as  soon  as  the  patient 
is  out  of  the  anesthetic.  Strychnia  hypodermically  in  doses  of 
1/30  of  a  grain  every  four  hours  and  atropin  hypodermically  in 
doses  of  1/200  of  a  grain  every  four  hours  are  given  to  combat 
the  intestinal  paresis.  On  the  occurrence  of  distention  high 
stimulating  enemas  such  as  alum  enemas  or  enemas  containing 
turpentine  are  given  frequently.  These  may  be  alternated  with 
enemas  not  producing  so  much  irritation  of  the  intestinal  mucosa; 
for  instance,  milk  and  molasses  enemas.  As  the  condition  is 
one  of  atony  a  secondary  operation  is  not  indicated,  though  in 
extreme  distention  multiple  incision  and  evacuation  of  many 
segments  of  the  intestine  may,  in  desperate  cases,  prove  of  value. 

Analagous  to  this  condition,  though  a  very  rare  complication, 
in  that  the  producing  cause  of  the  same  is  post-operative  general 
oozing  from  the  peritoneum  after  removal  of  large  growths  and 
sudden  relief  from  pressure.  It  will  be  noted  before  closing  the 
abdomen  that  oozing  occurs  from  different  points  of  the  parietal 
peritoneum,  particularly  in  the  neighborhood  from  which  the 
mass  was  removed. 

Treatment. — The  treatment  here  also  is  preventive.  The 
abdomen  is  filled  with  saline,  or  preferably,  saline  and  oxygen, 
and  a  tight  binder  applied.     Should  the  oozing  continue  as  shown 


OPERATIONS    UPON    THE    ABDOMEN  451 

by  continued  dullness  in  the  flanks  and  prolonged  shock  the 
usual  general  treatment  for  shock  and  hemorrhage  is  employed. 

Intestinal  paresis  follows  in  cases  of  long-continued  distention 
and  in  cases  in  which  the  muscular  wall  of  the  intestine  is  involved 
in  a  septic  process.  The  distention  is  relieved  to  a  slight  extent 
by  enemata  but  rapidly  recurs.  The  treatment  consists  in  re- 
peated enemata,  lavage,  elevated  head  and  trunk  posture,  single 
or  multiple  enterotomies,  the  formation  of  an  artificial  anus  and 
the  repeated  administration  of  doses  of  atropin  by  hypodermic. 
The  atropin  should  be  given  to  the  physiological  limit.  Paralysis 
of  the  bladder  and  mild  delirium  follow  its  use.  The  catheter 
will  be  necessary  in  the  former  event.     The  prognosis  is  bad. 

Hormonal. — Hormonal  is  a  name  given  to  a  preparation  of 
hormones,  substances  secreted  by  certain  cells  of  the  gastric 
mucosa  during  the  digestive  process,  the  physiological  action  of 
which  is  the  regulation  of  intestinal  peristalsis.  Zuelzer^  calls 
the  substance  peristaltic  hormone  and  after  experimentation 
determined  that  it  was  stored  in  the  spleen  and  in  largest  quan- 
tities at  the  height  of  digestion.  Zuelzer's  work  follows  along  the 
lines  initiated  by  Starling.^  Many  other  observers  are  investi- 
gating the  problem. 

Hormonal  is  prepared  by  macerating  under  aseptic  conditions 
the  spleen  of  a  guinea-pig  killed  at  the  height  of  digestion.  The 
spleen  is  macerated  and  extracted  with  physiologic  salt  solu- 
tion or  4/10  per  cent,  hydrochloric  acid.  The  extract  is  filtered; 
the  resulting  liquid,  if  protected  from  light,  remains  stable  for 
about  one  year.  According  to  the  experiments  of  Zuelzer  this 
substance  when  introduced  into  the  blood  stream  of  animals 
promptly  effects  vigorous  intestinal  peristalsis.  In  human  beings 
the  reaction  does  not  take  place  so  rapidly,  from  two  to  twenty-six 
hours  ensuing  before  its  manifestations  are  noted.  The  in- 
jection is  accompanied  by  a  slight  rise  of  temperature  which  dis- 
appears in  most  instances  after  twenty-four  hours.  No  anaphy- 
lactic phenomena  are  observed. 

During  the  past  two  years  a  number  of  favorable  reports  have 

'  Zuelzer,  Internationales  Zentralorgan  fiir  Blut  und  Serumforschung  II.  Folia  serologica, 
1910,  vol.  vi. 

^  Starling,  Zentralblatt  fiir  die  Physiologic  und  Pathologic  des  Stoffwechsels,  1907,  Nos. 
5  and  fr. 


452  OPERATIXG    ROOM    AND    THE    PATIENT 

been  made  both  in  the  treatment  of  post-operative  ileus  and 
chronic  constipation.  More  recently,  however,  certain  dangers 
have  been  point'ed  out. 

Dittler  and  Mohr^  found  that  a  marked  fall  in  blood  pressure 
regularly  follows  its  injection.  They  cite  a  case  convalescent 
from  pneumonia  accompanied  by  acute  hemorrhagic  nephritis 
in  which  14  c.c.  of  hormonal  were  given  intravenously  on  account 
of  persistently  troublesome  meteorism.  One-half  hour  later 
profound  collapse  occurred.  The  patient  responded  to  active 
stimulation  and  finally  recovered.     The  meteorism  lessened. 

Sabatowski^  from  the  result  of  animal  experimentation  and 
clinical  observation  concludes  that:  (1)  Intravenous  injections 
of  hormonal  are  followed  by  a  marked,  but  transient,  fall  in  blood 
pressure;  (2)  during  this  period  of  depression,  there  is  lack  of 
coagulability  of  the  blood,  and,  at  times,  marked  salivation;  (3) 
movements  of  the  intestine  are  somewhat  stimulated,  but  only  to 
the  degree  by  which  intestinal  peristalsis  is  increased  by  a  lowered 
blood  pressure;  (4)  neither  after  single  nor  repeated  injections 
(both  subcutaneous  and  intravenous),  was  an  effect  of  long  dura- 
tion observed;  (5)  hormonal  acts  neither  upon  the  gut  wall  nor 
upon  Auerbach's  ganglia;  the  effect  is  a  central  one,  and  is  evoked 
by  way  of  the  blood;  (6)  all  its  pharmacological  characteristics 
indicate  that  hormonal  contains  vasodilatin  (Popielski),  with 
which  its  action  is  identical.  Vasodilatin  is  obtained  from  ani- 
mal tissue  by  the  same  method  employed  in  preparing  hormonal. 

Sabatowski  tested  hormonal  clinically  on  eight  cases.  In 
these,  forty-eight  hours  were  allowed  to  elapse  before  considering 
the  effect  negative.  The  results  of  his  experience  showed  that: 
(1)  Large  doses  of  hormonal,  intravenously,  caused  sudden  fall 
in  blood  pressure,  loss  of  coagulability  of  the  blood,  and  an  in- 
significant increase  in  movements  of  the  intestine — all  these  mani- 
festations lasted  a.  short  while,  after  which  there  was  a  return 
to  normal;  (2)  following  intramuscular  injection,  the  above 
symptoms  were  barely  noticeable;  (3)  hormonal  acts  exactly  like 
Popielski' s  vasodilatin;  (4)  Sabatowski  warns  against  the  intra- 
venous use  of  hormonal  on  human  beings,  especially  after  an 

^  Mimch.  med.  Woch.,  1911,  No.  46,  pp.  24-27. 
2  Wien.  klin.  Woch.,  1912,  p.  116. 


OPERATIONS    UPON    THE    ABDOMEN  453 

anesthetic.  For  the  reason  cited  above,  the  preparation  has  no 
therapeutic  use.  The  observations  which  have  just  been  re- 
viewed would  seem  to  make  superfluous  any  further  argument 
about  the  vahie  of  hormonal. 

From  these  observations  it  must  be  deduced  that  hormonal  is 
still  in  the  experimental  stage,  at  least  so  far  as  post-operative 
treatment  is  concerned. 

Indications. — Hormonal  has  been  used  in  chronic  constipation 
of  the  atonic  as  well  as  the  mixed  atonic  and  spastic  type  and  in 
post-operative  intestinal  paresis.  Many  brilliant  results  have 
been  reported  in  the  latter  class  of  cases.  In  the  treatment  of 
chronic  constipation  H.  W.  Lincoln  reports  thirty-six  cases 
successfully  treated  out  of  a  total  of  sixty-seven. 

Administration. — Hormonal  is  furnished  in  vials  of  20  c.c. 
The  solution  for  intramuscular  administration  has  added  to  it  1/4 
per  cent,  beta-eucain  hydrochlorid.  The  dose  intramuscularly 
is  20  c.c.  administered  one-half  into  each  gluteal  region.  Intra- 
venous injection  is  preferable  to  intramuscular.  The  injection 
should  be  at  body  temperature.  Forty  cubic  centimeters  are  now 
advocated  by  Zuelzer  as  the  adult  dose;  in  children  one  to  fifteen 
cubic  centimeters  according  to  age.  The  patient  is  kept  quiet 
until  the  subsidence  of  the  reactive  temperature.  Castor  oil, 
one-half  to  one  ounce,  is  administered  two  to  four  hours  following 
the  injection.  If  the  patient  is  under  the  influence  of  opiates 
the  effect  of  hormonal  is  prevented. 

Post-operative  Intestinal  Obstruction. — Owing  to  the  improve- 
ment in  operative  technic,  post-operative  intestinal  obstruction 
is  not  nearly  so  common  as  formerly.  The  symptoms  of  obstruc- 
tion may  occur  immediately  after  operation,  or  may  be  delayed 
for  a  period  of  weeks  or  months,  or  even  years.  If  it  occurs 
immediately  after  operation  it  is  due  either  to  an  overlooked 
obstruction  complicating  the  conditions  for  which  the  operation 
was  done,  or  else  an  error  in  technic  at  the  operation  itself .  The 
omentum  or  even  the  intestine  has  been  caught  by  a  suture  in 
sewing  up  the  abdominal  incision;  violent  retching  may  force 
a  loop  of  intestine  between  two  sutures  in  case  individual  sutures 
have  been  used;  or,  a  portion  of  the  wound  may  be  ruptured  by 
severe  straining  caused  by  vomiting  and  a  loop  of  omentum  or 


454  OPERATING    ROOM    AND    THE    PATIENT 

intestine  forced  into  the  wound.  In  such  instances  it  is  usually 
the  small  intestine  that  is  involved  and  the  obstruction  is  acute. 
The  symptoms  are  vomiting,  pain  in  and  around  the  wound, 
distention  and  collapse.  Such  symptoms  occurring  soon  after 
abdominal  section  call  for  immediate  inspection  of  the  wound. 
The  large  intestine  may  be  the  seat  of  obstruction;  in  supra- 
vaginal hysterectomj'  in  suturing  the  utero-sacro  ligaments  to 
the  stump,  these  ligaments  are  dragged  upon  and  as  they  embrace 
the  rectum  they  constrict  it  even  to  the  extent,  in  some  instances, 
of  producing  total  obstruction.  This  should  be  suspected  in 
cases  of  hysterectomy'  developing  acute  obstruction  of  the  large 
intestine  immediately  following  operation.  Vaginal  and  rectal 
examination  reveal  the  ligaments  as  tense  bands  embracing  the 
rectum.  For  the  obstruction,  if  absolute,  a  colostomy  should 
be  performed  (Christopher  Martin). 

Another  form  of  post-operative  obstruction  occurring  follow- 
ing intraabdominal  gynecological  conditions  which  are  post- 
operatively complicated  by  an  hematocele  of  the  broad  ligament, 
is  that  in  which  the  hematocele  causes  an  annular  constriction 
of  the  rectum.  Whenever  obstruction  of  the  large  intestine 
immediately  follows  the  formation  of  the  hematocele  this  form 
of  constriction  should  be  suspected  and  rectal  examination  made. 
Usually  the  stricture  will  admit  the  forefinger,  but  in  rare  cases 
it  will  entirely  obstruct  the  lumen  of  the  bowel. 

Treatment. — The  hematocele  should  be  emptied  and  if  this 
does  not  give  relief  an  attempt  to  dilate  the  stricture  is  made.  If 
the  symptoms  are  urgent  colostomy  is  performed  (Christopher 
Martin) . 

Post-operative  Intestinal  Obstruction  due  to  Peritonitis. — The 
peritonitis  may  be  local  or  general.  If  local  a  single  loop  is  in- 
volved either  by  kink  through  plastic  exudate,  by  involvement 
of  the  muscular  coat  of  the  intestine  in  the  inflammation  or  by 
torsion  of  a  loop  of  intestine  through  plastic  exudate  in  the  mesen- 
tery. These  forms  of  obstruction  may  occur  as  the  result  of  the 
original  inflammation,  or  may  be  due  to  traumatism  at  the  time 
of  operation.  If  the  former,  the  symptoms  will  immediately 
follow  the  operation;  if  the  latter,  several  days  or  a  longer  interval 
will  elapse  before  symptoms  present.     The  symptoms  may  be 


OPEEATIONS  UPON  THE  ABDOMEN  455 

those  of  incomplete  obstruction,  recurring  attacks  of  painful 
distention  relieved  by  enemata  and  stomach  lavage. 

If  due  to  general  peritonitis  many  segments  of  the  intestine 
are  involved  through  infiltration  of  the  muscular  coat  by  septic 
inflammation.  Intestinal  paresis  rapidly  follows.  Treatment. — 
The  abdomen  is  opened  and  adhesions  are  separated.  The 
process  is  usually  so  extensive,  however,  that  in  most  cases 
treatment  will  prove  unavailing.  Occasionally  multiple  enter- 
otomies  with  emptying  of  the  various  distended  loops,  and  the 
establishment  of  an  artificial  anus  will  be  of  value. 

Post-operative  Obstruction  occurring  Weeks,  or  Months,  or  even 
Years  after  the  Operation. — The  same  causative  factors  are  re- 
sponsible as  in  the  cases  just  considered  but  it  is  not  until  time 
has  tightened  the  adhesions,  or  further  kinked  the  bowel,  or 
until  some  indiscretion  of  diet  has  produced  a  sudden  distention 
of  the  bowel  above  the  site  of  the  adhesions,  that  the  symptoms 
develop.     Treatment. — Immediate  laparotomy. 

Paracentesis  Abdominis. — In  general  ascites  the  site  selected 
for  puncture  is  in  the  linea  alba,  half  way  between  the  umbilicus 
and  the  pubes.  The  bladder  should  be  empty  and  the  patient 
should  be  placed  in  a  semi-sitting  posture.  Percussion  will 
show  dulness  from  the  symphysis  upward  toward  the  umbilicus, 
and  tympany  above,  the  dulness  representing  the  fluid,  and  the 
tympany  the  intestines  floating  above.  A  Scultetus  bandage 
should  be  passed  around  the  body,  the  ends  of  the  corresponding 
tails  of  the  bandage  being  held  in  place  by  the  first  half  of  a  knot. 
The  previously  sterilized  skin  is  incised  with  a  scalpel,  and  a 
straight  trocar  and  cannula  are  pushed  forcibly  and  quickly  into 
the  abdominal  cavity.  The  trocar  is  withdrawn,  and,  as  the 
fluid  flows  from  the  cannula,  it  is  caught  in  a  suitable  vessel.  As 
the  abdomen  decreases  in  size  the  tails  of  the  Scultetus  bandage 
are  drawn  together,  and,  when  the  fluid  ceases  to  flow  from  the 
cannula,  this  is  withdrawn  and  the  Scultetus  is  pinned  in  the 
usual  manner.  The  fluid  should  not  be  too  quickly  removed. 
The  Scultetus  bandage  serves  two  purposes;  it  causes  an  even 
flow  of  the  fluid,  and,  by  combating  the  loss  of  intraabdominal 
pressure  caused  by  the  withdrawal  of  the  fluid,  prevents  syncope. 

Operations  upon  the  Stomach.     Gastrostomy. — The  comfort 


456  OPERATIXG    ROOM    AXD    THE    PATIENT 

of  the  patient  depends  upon  the  technic  of  the  operation.  If  a 
permanent  fistula  is  desired  the  technic  of  Albert-Franks,  Witzel, 
Emanuel  Senn,  or  their  modifications  should  be  employed. 
Whatever  the  method  employed,  it  has  for  its  object  the  securing 
of  a  fistula,  through  ^vhich  nourishment  may  be  introduced 
through  a  tube  into  the  stomach,  and  which  will  prevent  the 
escape  of  gastric  juice.  If  there  is  suSicient  stomach  wall  to 
form  an  artificial  esophagus  two  inches  in  length  there  is  not 
much  likelihood  of  leakage. 

After-treatment. — The  wound  heals  without  complication  if 
the  escape  of  gastric  juice  is  prevented.  Should  gastric  juice 
escape,  it  must  be  remoA'ed  immediately  from  the  wound  surfaces. 
Othei'wise  it  will  irritate  the  skin  and  set  up  an  obstinate  eczema. 
Dressings  are  changed  frequently,  and  the  parts  cleansed  with 
normal  salt  solution  if  leakage  occurs,  A  tube  should  be  left 
in  the  fistula  which  will  completely  fill  it,  so  that  for  the  first  few 
daj's  at  least  no  gastric  juice  will  come  in  contact  with  the  wound. 
Further  protection  is  afforded  by  painting  the  wound  surface 
with  Wolfler's  solution.  In  order  to  prevent  the  escape  of  gastric 
juice  through  the  tube,  its  lumen  is  closed  by  clamping  the  tube. 
As  this  operation  is  usualh^  performed  on  patients  who  have 
become  or  are  rapidly  becoming  emaciated  by  reason  of  a 
cicatricial  or  malignant  closure  of  some  portion  of  the  esophagus, 
nourishment  must  be  begun  immediately.  Saline  enemata  are 
given  every  few  hours.  In  addition  liciuid  nourishment  is  to  be 
introduced  into  the  stomach  through  the  tube  as  soon  as  the 
primary  effects  of  the  anesthetic  liaA'e  passed  off.  Two  ounces 
of  warm  peptonized  milk  are  introduced  ever}"  two  hours  for 
the  first  twenty-four  hours.  During  the  second  and  third 
twenty-four  hours  two  ounces  may  be  given  ever}-  hour.  Equal 
amounts  of  other  fluids  may  be  given  alternately  with  the  milk. 
At  no  time  until  healing  is  complete  is  a  large  amount  of  fluid  to 
be  introduced  into  the  stomach.  After  the  fifth  day  six  ounces 
at  a  time  may  be  given,  and  after  the  second  week  larger  amounts. 
A  list  of  fluid  and  farinaceous  food  is  furnished  the  patient  who 
is  instructed  in  feeding  himself.  The  diet  should  include  albu- 
min, fats  and  carbohydrates.  A  funnel  is  used  in  conjunction 
with  the  tube.     The  patient  may  masticate  the  food  first  and 


OPERATIOXS  UPON  THE  ABDOMEN  457 

then  place  it  in  the  funnel.  By  so  doing  a  greater  variety  of 
food  may  be  given  and  all  the  pleasure  of  eating  and  drinking 
with  the  exception  of  the  actual  act  of  swallowing  is  enjoyed. 
It  will  be  found  that  if  the  tube  is  allowed  to  remain  in  place 
permanently,  it  will  not  only  be  eroded  by  the  gastric  juice  but 
will  in  time  cause  a  dilated  condition  of  the  fistulous  tract, 
allowing  gastric  juice  to  escape  alongside  it.  It  is  better,  there- 
fore, after  wound  healing  is  complete,  to  remove  the  tube  except 
during  the  periods  of  feeding.  Should  there  be  a  tendency  of 
the  artificial  esophagus  to  close  the  tube  should  be  retained  for 
longer  periods.  The  escape  of  gastric  juice  is  prevented  by 
gentle  elastic  pressure  over  the  fistulous  tract,  causing  the  walls 
of  the  fistula  to  come  in  contact.  In  the  Albert-Franks  or  similar 
operations  even  this  is  not  necessary,  as  the  pressure  of  the 
muscular  walls  of  the  abdomen  is  sufficient  to  keep  the  walls 
of  the  fistulous  tract  in  contact,  and  thus  prevent  the  escape  of 
stomach  contents.  Apparatus  which  act  by  plugging  the  fistula 
are  to  be  avoided,  because  even  if  they  are  successful  for  a  time, 
they  will  finally  cause  a  dilatation  of  the  fistula. 

Retrograde  Dilatation  of  the  Esophagus. — If  such  a  procedure 
is  employed  the  after-care  is  carried  out  on  the  lines  already 
laid  down.  As  the  stomach  opening  is  larger  than  in  ordinary 
gastrostomy,  more  care  is  necessary,  both  to  prevent  the  escape 
of  stomach  contents  and  to  keep  up  the  nutrition  of  the  patient. 

Closure  of  the  Fistula. — Should  the  primary  condition  which 
necessitated  the  operation  be  cured  and  the  probable  permanent 
permeability  of  the  esophagus  be  assured,  the  fistula  may  be 
closed.  This  will  necessitate  laparotomy,  with  careful  dissection 
of  the  artificial  esophagus  (fistula),  the  closure  of  the  opening 
in  the  stomach,  and  the  closure  of  the  abdominal  wall.  Caustics 
or  the  thermocautery  are  not  to  be  employed  in  an  attempt  to 
close  the  fistula. 

Gastrotomy. — This  operation  is  performed  most  frequently 
for  the  removal  of  foreign  bodies,  infrequently  for  the  divulsion 
of  stricture  of  the  esophagus.  If  the  patient  is  a  robust  one, 
nutrition  may  be  kept  up  by  enemata  alone  for  three,  four  or 
five  days.  If  the  patient  is  weak,  it  will  not  be  safe  to  wait  this 
long  before  giving  some  nourishment  by  the  stomach  as  well. 


458  OPERATING    ROOM    AXD    THE    PATIEXT 

For  this  purpose,  should  great  weakness  be  present,  ounce  doses 
of  peptonized  milk  may  be  given  at  frequent  intervals.  If 
such  a  course  is  followed  it  must  be  remembered  that  healing 
of  the  wound  may  be  interfered  with  by  the  motility  of  the 
stomach,  and  the  question  resolves  itself  into  whether  it  is  safer 
to  allow  an  already  emaciated  patient  to  perish  of  inanition  or 
run  the  risk  of  giving  small  quantities  of  liquid  nourishment  by 
mouth.  Each  case  must  be  decided  on  its  merits.  Liquid  food 
may  be  given  in  larger  quantity,  four  ounces,  after  the  fifth  day 
without  danger.  The  amount  of  each  individual  dose  is  gradu- 
ally increased  until,  by  the  tenth  day,  the  patient  is  taking 
ninety  ounces  a  day.  Farinaceous  diet  may  then  be  given,  and 
after  the  second  week  solid  food  be  gradually  resumed. 

Gastrorrhaphy. — This  operation  is  necessitated  by  wounds  of 
the  stomach,  and  as  the  patients  are  well-nourished  as  a  rule, 
rectal  enemata  will  suffice  until  the  fifth  day,  following  which 
small  doses  of  liquid  nourishment  may  be  given  by  the  stomach, 
as  in  gastrotomy.  C 0772 plications  are  to  be  watched  for,  as  other 
viscera  may  have  been  injured,  notably  the  pancreas,  or  infection 
may  have  entered  with  the  weapon  or  missile. 

Gastroenterostomy. — The  anastomosis  is  usually  made  poste- 
riorly with  a  short  loop  (the  no-loop  operation  of  Maj^o) . 

Malignant  cases  present  themselves  for  operation  after  they 
have  exhausted  the  resources  of  medicine.  Consequently  the 
operation  is  a  last  resort  and  these  patients  are  particularly 
poor  subjects  for  any  operative  procedure.  They  are  reduced 
in  strength  by  weeks  or  months  of  semi-starvation. 

The  most  we  can  promise  is  the  relief  of  the  malnutrition. 
This  is  explained  to  the  patient's  friends,  though  not  necessarily 
to  the  patient.  It  is  not  advisable  to  take  from  any  patient  the 
victim  of  an  incurable  disease  the  last  ray  of  hope,  and  so  per- 
haps embitter  the  few  remaining  months  of  life.  Should  the 
operation  prove  successful  the  patient's  condition  will  be  greatly 
improved.  He  will  increase  in  weight  and  be  free  from  the 
terrible  gnawings  of  hunger.  By  allaying  the  irritation  pro- 
duced by  the  passage  of  food  through  the  pylorus,  for  the 
stenosis  is  rarely  absolute  and  small  quantities  of  fluid  will  pass, 
the  rapidity  of  the  malignant  growth  is  decreased.     In  some 


OPERATIONS  UPON  THE  ABDOMEN  459 

cases  an  almost  curative  effect  is  obtained  and  the  disease  may 
remain  stationary  for  a  long  period.  In  nonmalignant  cases 
(duodenal  ulcer)  the  relieving  of  irritation  in  time  effects  a 
complete  cure. 

Complications.  Aside  from  those  resulting  from  the  disease 
itself,  these  are  mostly  traceable  to  errors  in  technic.  Nor 
are  these  always  avoidable.  Intractable  Vomiting. — This  may 
follow  anesthesia,  as  in  other  operations,  and  the  continued 
movements  of  the  stomach  must  have  a  weakening  effect  upon 
the  sutures.  In  many  of  these  cases  no  general  anesthetic  is 
employed,  yet  vomiting  sets  in  and  persists  and  the  patient  dies 
from  exhaustion.  Some  of  the  cases  are  explainable  on  the 
ground  of  faulty  anastomosis.  The  intestinal  loop  selected  for 
the  anastomosis  may  have  been  too  distant  from  the  duodenum. 
Stomach  contents  may  enter  the  proximal  anastomotic  loop 
instead  of  the  distal  loop.  The  sutures  securing  the  opening 
in  the  mesentery  of  the  transverse  colon  may  loosen  allowing  the 
opening  to  descend  on  the  intestinal  loops  and  so  occlude  them. 
The  site  of  the  anastomosis  may  be  so  dragged  upon  as  to  close 
or  partially  close  its  opening;  the  gut  below  the  anastomosis  may 
be  closed  by  kinking  or  adhesion.  Such  conditions  are  demon- 
strable. There  still  remains  a  class  of  cases  which  die,  exhausted 
by  intractable  vomiting,  and  in  which  at  autopsy  no  sufficient 
cause  can  be  found.  In  such  cases  there  must  be  reversed 
peristalsis  of  the  stomach.  There  is  no  other  way  to  account  for 
the  intractable  vomiting.  Employing  the  no-loop  method  of 
Mayo   will    give    most    satisfactory   results. 

Formerly  nourishment  was  maintained  by  nutrient  enemata 
until  the  fifth  day.  The  cases  are  few  in  number,  however, 
which  can  stand  long  abstinence  from  feeding  by  stomach. 
Weakness  and  exhaustion  become  pronounced  and  nourishment 
must  be  given  by  the  stomach  or  these  patients  will  die.  Here, 
as  in  all  intestinal  anastomoses,  the  wound  is  weakest  from  the 
third  to  the  fifth  day,  following  which  union  progressively  becomes 
firmer  and  is  practically  complete  on  the  ninth  day.  However, 
if  the  technic  elaborated  by  Mayo  is  used  the  cases  can  be  given 
water  at  the  end  of  twenty-four  hours,  at-  first  one  ounce  each 
hour.     If  nausea  is  not  produced  the  amount  is  gradually  in- 


460  OPERATING    ROOM    AXD    THE    PATIENT 

creased  until  at  the  end  of  twenty-four  to  forty-eight  hours  more 
the  case  is  given  other  fluids.  To  tide  over  the  thirst  of  the  first 
twenty-four  hours  Murphy  proctoclysis  is  used.  Farinaceous 
food  is  added  after  the  seventh  day  and  normal  feeding  on  the 
tenth  day.  These  patients  should  be  instructed  to  chew  their 
food  well. 

Should  continued  vomiting  occur,  the  stomach  is  carefully 
washed  out,  feeding  by  the  stomach  stopped,  and  the  head  of 
the  bed  raised  eighteen  inches  to  favor  normal  peristaltic  move- 
ments and  to  employ  the  aid  of  gravity  in  causing  the  stomach 
secretions  to  flow  out  of  the  anastomotic  opening.  Should 
small  intestinal  contents  and  bile  be  vomited,  and  this  is  not  re- 
lieved by  lavage,  the  elevated  head  and  trunk  position  and  the 
emploj^ment  of  stimulating  enemata  to  promote  normal  peristal- 
sis, a  second  operation  must  be  performed  and  the  two  loops  of 
the  anastomosis  opened  and  made  to  communicate  so  that  com- 
plete drainage  of  the  proximal  loop  will  be  effected,  and  by  no 
possibility  can  the  proximal  loop  become  filled  and  empty  into 
the  stomach.  Such  a  condition  is  highly  improbable  if  the  no- 
loop  method  is  employed.  It  is  unnecessary  to  say  that  such 
an  operation  holds  out  small  hope  of  saving  the  patient.  Death 
may  ensue  in  gastroenterostomy  for  malignant  disease  in  from 
one  to  four  days  as  the  result  of  inanition.  In  cases  in  which  the 
technic  has  been  perfect,  and  in  subjects  whose  reparative  powers 
are  sufficient  to  withstand  the  restricted  diet  for  a  few  days 
following  the  operation,  improvement  is  marked.  Cases  of 
dilatation  of  the  stomach  and  obstruction  of  the  pylorus  with 
cicatricial  or  spasmodic  stricture  from  the  proximity  of  an  ulcer, 
are.j,  cured.  Duodenal  ulcer  cases  are  cured.  Malignant  cases 
are  so  improved  that  one  sometimes  doubts  the  correctness  of  the 
diagnosis.  Of  course  in  the  latter  cases  the  improvement  is  only 
transitory. 

Jejunostomy. — Jejunal  feeding.  Liquid  food  may  be  given 
at  the  completion  of  the  operation.  If  Mayo's  method^  is  fol- 
low^ed  there  is  no  danger  of  leakage,  nor  does  leakage  follow  the 
removal  of  the  tube.  If  the  tube  should  slip  out  accidentally 
it  should  be  replaced  within  twelve  hours  or  the  tract  may  be- 

^  American  Journal  of  the  Medical  Sciences,  vol.  cxliii,  p.  469. 


OPERATIONS  UPON  THE  ABDOMEN  461 

come  obliterated.  All  kinds  of  liquid  food  are  applicable:  Milk, 
eggs,  meat  ground  fine  and  mixed  with  fluid,  carbohydrates  in 
liquid  form,  etc.  The  food  should  be  administered  slowly,  fif- 
teen to  twenty  minutes  for  each  eight  ounces  at  body  temperature 
as  in  duodenal  feeding  by  the  Einhorn  method.  Before  and  after 
each  feeding  a  small  quantity  of  saline  should  be  run  through  the 
tube  to  cleanse  it.  Preferably  feedings  are  at  frequent  intervals, 
every  two  hours  at  first  using  6  to  8  ounces;  later  every  fovir 
hours  using  larger  quantities.  The  patient  may  be  allowed  to 
hold  the  fluid  in  his  mouth  thus  mixing  it  with  the  saliva  and  then 
ejecting  it  into  a  funnel  connected  with  the  tube.  The  bed  may 
be  screened  while  the  patient  is  feeding  himself  if  he  is  sensitive 
of  observation.  He  must  be  warned  not  to  swallow  the  food. 
At  the  end  of  a  week  or  later  if  the  chromic-gut  stitch  holding  the 
tube  in  place  has  not  been  absorbed,  the  tube  is  removed  be- 
tween feedings  for  purposes  of  cleanliness.  As  before  noted  it 
should  not  be  left  out  longer  than  twelve  hours.  If  there  is  a 
tendency  for  the  fistulous  tract  to  contract  the  tube  need  not  be 
removed  so  frequently;  on  the  other  hand  if  there  is  a  tendency 
of  the  tract  to  become  more  patent  the  tube  can  be  left  out  for 
longer  intervals.  Following  the  final  removal  of  the  tube  the 
tract  rapidly  closes,  usually  without  leakage.  No  subsequent 
ill  effects  from  the  jejunostomy  have  heen  observed.  Patients 
gain  rapidly  in  weight  as  a  rule.  The  operation  is  particularly 
indicated  in  any  lesion  calling  for  rest  of  the  stomach  and  at  the 
same  time  maintains  excellent  nutrition. 

Gastrectomy,  Complete  or  Partial ;  Pylorectomy. — The  nourish- 
ment of  the  patient  is  carried  out  as  in  gastroenterostomy. 
Much  of  what  has  been  said  concerning  the  latter  operation 
applies  here.  Malignant  cases  which  survive  the  operation  will 
improve  rapidly  for  a  time.  In  cases  in  which  the  greater  part 
or  all  of  the  stomach  is  removed,  partially  digested  food  must  be 
used  so  that  the  small  intestine  receives  the  food  as  it  would  come 
from  a  normal  stomach. 

A  complication  which  may  follow  these  operations  is  gangrene 
of  the  transverse  colon  due  to  inj  ury  to  its  blood  supply.  These  cases 
do  well  for  four  or  five  days  at  which  time  the  gangrene  of  the 
transverse  colon  results  in  peritonitis  with  a  final  fatal  result. 


462  OPERATING    ROOM    AXD    THE    PATIENT 

This  complication  was  formerly  common  but  owing  to  improved 
technic  is  rarely  seen  at  the  present  day. 

Suspension  Operations  upon  the  Abdominal  Viscera. — These 
cases  require  longer  rest  in  bed  than  ordinary  cases,  twelve  days 
being  the  usual  length  of  time.  The  abdominal  binder  is  rein- 
forced and  applied  with  great  care  so  as  to  support  the  suspended 
organ. 

Operations  upon  the  Intestines  done  in  Two  Stages  (Mikulicz 
Operation). — It  is  at  times  desirable  in  the  case  of  a  tumor  the 
immediate  removal  of  which  would  involve  to®  great  a  dissection 
with  immediate  grave  risk  to  life  to  loosen  the  portion  of  the  in- 
testine the  seat  of  the  growth  and  fasten  it  outside  the  abdominal 
wall.  If  obstruction  is  present  the  intestine  is  either  immediately 
opened  or,  if  possible  to  delay  it,  at  the  end  of  twenty-four  hours. 
At  the  end  of  forty-eight  hours,  adhesions  having  formed,  the 
mass  is  cut  away.  The  primary  dressing  consists  of  abundant 
fluffed  out  gauze.  This  is  changed  several  times  daily  as  soiled. 
Later  a  secondary  operation  either  by  Mickulicz  clamp  or  a 
formal  laparotomy,  is  undertaken  to  restore  the  continuity  of 
tlie  intestinal  canal. 

Appendicitis. — Interval  cases  are  treated  as  any  clean  laparot- 
omy. Acute  cases  limited  to  the  appetidix  or  with  but  slight 
local  peritonitis  are  treated  similarly.  The  peritoneum  easily 
cares  for  the  peritonitis.  In  these  cases  the  only  complication 
will  be  possible  superficial  wound  infection  from  some  of  the 
infection  from  the  appendix  being  transferred  to  the  wound  in 
the  course  of  the  operation.     The  treatment  is  preventive. 

Appendicitis  with  more  marked  local  peritonitis  or  in  which 
excision  of  the  appendix  ivas  accompanied  by  traumatisrn.  causing 
oozing  for  which  drainage  has  been  used. — These  cases  are  treated 
similarly  to  the  above  with  the  exception  of  the  drain  which  is 
removed  at  the  end  of  forty-eight  hours  and  replaced  by  a  drain 
down  to  the  peritoneum.  This  is  removed  after  twenty-four 
hours.  As  a  rule  no  further  wound  treatment  is  required.  The 
patient  is  not  allowed  up  until  twenty-four  hours  after  removal 
of  the  drain  and  not  then  if  the  drainage  opening  has  been  large. 

Appendicitis  with  Localized  Abscess. — If  the  abscess  is  well 
walled  off  and  the  peritoneal  cavity  not  invaded  at  the  operation 


OPERATIONS  UPON  THE  ABDOMEN  463 

the  treatment  is  as  in  the  above  with  the  exception  of  the  treat- 
ment of  the  drain.  The  outer  dressings  are  kept  moistened  to 
promote  drainage;  the  drain  is  shortened  at  the  end  of  each 
twenty-four  hours  and  removed  by  the  fourth  day  when  it  is 
replaced  by  a  smaller  drain.  The  wound  is  dressed  daily, 
shortening  the  drain  or  using  less  of  a  drain  with  each  dressing. 
The  patient  is  placed  in  a  position  which  will  favor  drainage, 
usually  with  a  pillow  under  the  opposite  hip. 

Appendicitis  with  Spreading  Peritonitis  without  Local  Condi- 
tions requiring  drainage. — Infection  of  the  wound  may  occur 
as  in  all  acute  cases.  The  stomach  is  kept  empty  for  twenty-four 
to  forty-eight  hours  or  until  twelve  hours  following  approxi- 
mately normal  temperature  when  all  signs  of  peritonitis  have 
subsided.  If  vomiting  occurs  lavage  is  employed  siphoning 
the  stomach  dry.  The  elevated  head  and  trunk  position  is 
used  to  cause  slower  absorption  of  the  peritoneal  effusion. 
The  peritoneum  serves  as  its  own  scavenger  and  drinks  up  the 
outlying  infection.  Slowly  given  saline  enemata  every  three  or 
four  hours  or  Murphy  proctoclysis  every  alternate  two  hours 
serves  to  dilute  the  peritoneal  infection  and  less  reaction  is 
observed  from  its  absorption. 

Appendicitis  with  spreading  peritonitis  with  local  conditions 
requiring  drainage  are  treated  as  above  and  the  drain  is  treated 
as  in  appendicitis  with  abscess. 

Appendicitis  with  diffuse  septic  peritonitis  is  treated  by  a  large 
glass  tube  to  the  pelvis,  such  local  drainage  as  is  indicated,  the 
elevated  head  and  trunk  position,  nothing  by  stomach  (the  mouth 
may  be  rinsed  frequently  if  nothing  is  swallowed),  lavage  with 
dry  siphoning  if  vomiting  occurs.  The  stomach  is  kept  empty  to 
limit  peristalsis  and  saline  enemas  are  slowly  given  every  three 
or  four  hours  or  Murphy  proctoclysis  to  dilute  toxins.  After 
forty-eight  hours  or  longer,  or  twelve  hours  after  the  temperature 
is  approximately  normal  dram  doses  of  water,  hot  or  cold,  are 
given  every  fifteen  minutes  and  if  no  rise  of  temperature  results 
the  size  of  the  dose  is  gradually  increased  aiid  the  intervals 
gradually  lengthened  and  at  the  end  of  a  few  hours  broth  is 
added.  Thereafter  the  quantity  is  rapidly  increased  so  that  at 
the  end  of  twenty-four  hours  or  at  most  thirty-six  hours  full 


464  OPERATIXG    ROOM    AXD    THE    PATIENT 

fluid  diet  is  reached.  As  the  quantity  of  fluid  is  increased  by 
mouth  the  amount  by  rectum  is  lessened.  Treatment  of  the 
Drain. — The  local  drain  is  treated  as  already  outlined.  The 
tube  to  the  pelvis  has  its  loose  drainage  strip  removed  at  the  end 
of  four  hours,  and  the  tube  is  aspirated  with  a  "sucker"  and  a 
new  strip  loosely  packed  in.  This  procedure  is  repeated  at  first 
every  four  hours  and  later  as  the  amount  of  discharge  decreases 
at  six-  and  eight-hour  intervals.  Usuall}^  on  the  third  day  the 
discharge  is  slight  and  then  the  large  tube  is  replaced  by  a  smaller 
rubber  tube  passed  to  the  bottom  of  the  glass  tube,  and  held 
in  place  while  the  glass  tube  is  withdrawn,  following  which  the 
wound  is  dressed  daily  and  the  tube  gradually  shortened.  After 
the  seventh  day  this  tube  is  removed  a  still  smaller  tube  taking- 
its  place  and  the  shortening  process  repeated.  When  the  tube  is 
shortened  so  that  it  does  little  more  than  extend  through  the 
abdominal  wall  it  is  removed  entirely  and  a  gauze  strip 
substituted. 

Cases  -presenting  evidence  of  general  infection  are  treated  as  are 
all  general  infections,  at  first  by  stock  vacines,  later  by  autog- 
enous vaccines. 

Complications. — Any  case  of  acute  appendicitis  may  develop 
any  complication  arising  from  infection  anywhere  or  occurring 
after  any  operation.  These  complications  are  almost  all  avoided 
by  very  early  operation,  therefore,  the  prevention  of  complica- 
tions is  for  the  most  part  in  the  hands  of  the  general  practitioner. 
Certain  locations  of  the  appendix  favor  certain  complications  as, 
for  instance,  if  an  acutely  inflamed  appendix  is  in  relation  with 
the  mesentery  of  the  small  intestines  infection  through  the  blood 
stream  of  distant  parts  is  more  likely  to  follow. 

Operations  for  the  Purpose  of  Intestinal  Irrigation  in  Chronic 
Inflammatory  Diseases  of  the  Colon.  Dysentery.  Colitis. 
Enterocolitis.  Appendicostomy. — At  the  end  of  forty-eight  hours 
sufficient  adhesion  has  taken  place  between  the  appendix  and 
the  wound  to  prevent  leakage.  "Without  anesthesia  the  extrud- 
ing portion  of  the  appendix  is  cut  off  one-quarter  of  an  inch 
above  the  abdominal  wall,  A  rubber  catheter  is  inserted  through 
the  appendix  into  the  cecum  and  colonic  irrigation  begun. 
Many   varieties   of   irrigation    are  recommended;  of  the  silver 


OPERATIONS  UPON  THE  ABDOMEN  465 

preparations,  argyrol  1-1000;  protargol  1-100;  silver  nitrate 
1-2000.  In  amebic  dysentery  quinin  sulphate  solutions 
1-750  to  1-1500  are  especially  indicated,  either  in  weak  or  strong 
solutions.  In  the  latter  class  of  cases  Manson  recommends  silver 
nitrate  1-1000  following  preliminary  saline  irrigation.  All  medi- 
cated irrigations  should  be  preceded  by  a  large  cleansing  flush- 
ing of  one  or  more  gallons  of  saline.  The  patient  can  be  in- 
structed in  this  method  of  irrigation  after  wound  healing  has  been 
effected.  The  usual  time  for  wound  healing  is  as  for  other  lapa- 
rotomy wounds,  but  the  patient  is  kept  quiet  in  bed  longer  on 
account  of  the  possibility  of  wound  infection  through  the  intes- 
tinal opening.  Daily  irrigations  are  indicated.  For  the  first 
irrigation  it  may  be  necessary  to  pass  a  rectal  tube  after  intro- 
ducing the  fluid  into  the  colon  but  the  patient  quickly  learns  to 
relax  the  sphincter  ani  so  that  he  can  control  the  distention  of 
the  colon.  The  improvement  under  this  method  is  extraordinary. 
Patients  pick  up  flesh,  are  relieved  of  their  pain,  are  able  to  eat 
practically  any  ordinary  food.  The  diarrheal  condition  is  re- 
placed by  one  thorough  and  painless  evacuation  occurring  coin- 
cident with  the  irrigation.  This  allows  the  patient  to  get  about. 
Weight  and  strength  increase.  In  the  milder  infections  cure  is 
rapid  and  even  in  chronic  cases  of  amebic  dysentery  cure  is 
more  likely  to  occur  than  under  any  other  method  of  treat- 
ment. 

Later,  after  the  indications  for  its  use  have  disappeared,  a 
plastic  operation  closes  the  appendicostomy  opening. 

Valvular  Cecostomy. — Where  it  is  not  possible  to  use  the  appen- 
dix for  the  irrigation  opening  either  by  reason  of  its  location  or 
because  of  its  condition,  a  valvular  opening  similar  to  that  in 
Senn's  gastrostomy  is  made  and  a  small  catheter  inserted, 
secured  by  fine  catgut  to  the  funnel-shaped  opening  in  the  cecum, 
the  cecum  itself  being  attached  to  the  abdominal  wall.  After 
such  an  operation  colonic  irrigation  may  be  begun  at  once. 

Gant's  Operation. — Gant,  in  cases  of  enterocolitis,  through  a 
plastic  operation  upon  the  colon  places  two  small  catheters,  one 
in  the  small  intestine  and  one  in  the  large  intestine,  so  that  irri- 
gation of  both  can  be  carried  out. 

Artificial  Anus. — Following  artificial  anus  done  for  gangrene  of 

30 


466  OPERATING    ROOM    AND    THE    PATIENT 

the  intestine  even  if  the  operation  itself  is  not  severe  the  patients 
will  usually  die  of  general  debility  or  peritonitis  in  from  twenty- 
four  to  forty-eight  hours.  The  case  has  usually  progressed  too 
far  before  surgical  measures  are  instituted.  Done  formally 
the  prognosis  is  good.  The  after-treatment  is  troublesome. 
The  suture  line  is  painted  with  collodion  or  Wolfler's  peritoneal 
varnish.  An  abundant  absorbent  dressing  of  paper  wool  covers 
the  wound;  this  is  renewed  every  three  hours.  The  wound  in 
the  neighborhood  of  an  artificial  anus  is  particularly  liable  to 
infection  from  the  presence  of  the  discharges.  Immediately 
upon  the  appearance  of  infection  the  sutures  should  be  removed. 
The  infection  may  be  deep-seated  and  not  show  at  first  except 
through  the  temperatiu-e;  in  such  cases  the  sutures  are  removed 
and  the  wound  opened.  This  will  present  a  nasty  sloughing 
appearance.  A  moist  antiseptic  dressing  hastens  the  separa- 
tion of  the  sloughs. 

Skin  irritation  may  be  prevented  in  part  by  anointing  the  skin 
in  the  neighborhood  of  the  artificial  anus  with  vaselin.  A  moist 
eczema  is  liable  to  develop  and  can  only  be  kept  in  check  by  strict 
cleanliness.  After  a  week  or  ten  days  when  wound  healing  has 
become  somewhat  firm  the  patient  may  be  placed  in  a  warm  bath 
for  one-half  hour  twice  daily;  this  is  a  source  of  great  comfort 
to  the  patient,  and  cleanses  the  wound.  The  granulations  in  the 
neighborhood  of  an  artificial  anus  are  apt  to  become  grayish 
owing  to  the  discharge.  The  sutures  which  are  used  to  hold  the 
intestine  in  position  as  a  rule  take  care  of  themselves;  they  loosen 
and  come  away.  The  wound  cicatrizes  slowly,  the  mucous 
membrane  of  the  gut  proliferates  until  finally  cicatrization 
between  it  and  the  skin  is  complete. 

The  effect  of  an  artificial  anus  upon  the  general  health  depends 
upon  the  portion  of  the  intestine  from  which  the  anus  was 
formed.  If  in  the  sigmoid  nutrition  does  not  suffer;  if  in  the 
cecum  or  the  small  intestine  in  the  neighborhood  of  the  ileocecal 
valve  nutrition  is  not  markedly  interfered  with.  It  is  to  be  borne 
in  mind,  however,  that  it  is  in  the  large  intestine  that  absorption 
of  fluid  for  the  most  part  takes  place.  The  higher  up  in  the  small 
intestine  the  fistula  is  placed  the  more  marked  the  inanition. 
If  in  the  duodenum  or  jejunum  inanition  rapidly  follows  and  the 


OPERATIONS  UPON  THE  ABDOMEN  467 

patient  dies  of  debility.  If  high  up  in  the  ileum  patients  may 
live  for  some  weeks  or  months.  The  only  treatment  for  fistula 
placed  high  up  is  early  operation  before  the  patient  has  become 
too  much  enfeebled.  The  site  of  the  fistula  can  be  determined 
by  the  character  of  the  stools.  The  patient  should  be  weighed 
daily,  and  if  loss  of  weight  is  shown  operation  should  not  be 
delayed.  The  diet  should  be  highly  nutritious  and  such  as  to 
leave  the  smallest  possible  residuum  in  the  intestines.  Soup, 
eggs,  milk,  farinaceous  food,  scraped  beef,  peptones,  rice  pudding, 
young  chicken,  lamb,  form  the  best  diet;  this  is  supplemented  by 
rectal  alimentation.  Jejunal  Feeding. — An  attempt  may  also 
be  made  to  place  predigested  foods  in  the  efferent  loop  of  the 
fistula.  If  this  is  possible  it  not  only  nourishes  the  patient 
better  but  prevents  contracture  of  the  portion  of  the  bowel 
below  the  fistula.  Reverse  peristalsis  tends  to  prevent  feeding 
through  the  efferent  loop.  Spontaneous  closure  while  possible 
should  not  be  waited  for  as  in  the  meantime  the  patient  is  losing 


Fig.  193. — Dupuytren's  clamp. 

more  and  more  strength.  The  only  radical  treatment  is  an  early 
operation  either  intraabdominal  or  by  Dupuytren' s  clamp  (Fig. 
193)  and  a  subsequent  plastic  operation.  After  operating  by 
means  of  Dupuytren's  clamp  it  will  be  necessary  to  quiet  the  pain 
with  opium.  It  takes  six  or  eight  days  for  the  clamp  to  ulcerate 
through;  in  the  meantime  adhesions  form  which  guard  the  peri- 
toneal cavity  against  infection.  If  the  attempt  is  successful  a 
fecal  fistula  results  in  place  of  the  artificial  anus,  the  fecal  current 
for  the  most  part  passing  along  the  channel  made  by  the  clamp. 
This   may  be   aided   by  plugging  the   external  wound.     Such 


468  OPERATING    ROOM    AND    THE    PATIEXT 

fistulse  have  a  tendency  to  close,  but  it  is  better  to  aid  in  their 
closure  by  a  plastic  operation. 

Inability  of  the  Artificial  Anus  to  Functionate. — Occasionalh' 
it  happens  that  while  gas  passes  more  or  less  freely  through  the 
tube  usually  left  in  the  enterostomy  opening  at  the  time  of 
operation,  yet  the  passage  of  fecal  matter  does  not  occur.  A 
condition  of  partial  obstruction  is  present.  This  may  be  due 
to  too  much  traction  on  the  intestine  or  to  too  tight  closure  of 
the  abdominal  wound  in  an  attempt  to  make  an  ideal  anus,  or 
to  paresis  of  the  loop  operated  upon.  It  is  overcome  by  inserting 
the  tube  further  into  the  gut  and  the  use  of  frequent  enemas 
through  the  tube. 

Fecal  Fistula. — If  the  fistula  is  small  and  free  drainage  exists 
healing  may  be  expected  without  further  operative  interference. 
The  lower  bowel  should  be  kept  empty  by  enema  night  and  morn- 
ing. The  diet  should  be  such  as  to  leave  the  smallest  possible 
residuum  in  the  intestine.  If  there  is  any  tendency  to  fecal 
phlegmon  the  external  'wound  should  be  freely  opened.  If  the 
fistula  is  of  larger  size  with  eversion  of  mucous  membrane,  or 
if  it  is  persistent,  a  secondary  plastic  operation  must  be  under- 
taken for  its  cure.  The  dressing  in  all  fecal  fistulse  should  be 
changed  every  two  or  three  hours,  and  the  skin  in  the  neighbor- 
hood kept  clean  and  well  greased  in  order  to  avoid  eczema.  If 
a  plastic  operation  for  the  cure  of  the  fistula  fails,  a  formal 
laparotomy  must  be  undertaken,  and  either  resection  or  short 
circuiting  of  that  portion  of  the  intestine  the  site  of  the  fistula 
done. 

Herniotomy.  Inguinal. — The  after-treatment  of  herniotomy 
varies  according  to  the  conditions  present  at  the  operation. 
Simple  cases  in  which  neither  inflammation  nor  obstruction 
is  present  follow  an  uncomplicated  course,  cases  which  are 
inflamed  and  obstructed  are  somewhat  more  difficult  to  care 
for,  while  tjiose  cases  in  which  gangrene  is  present  may  offer 
many  complications. 

Radical  Cure  in  Simple  Cases. — Though  the  technic  of  the 
operation  varies,  the  after-course  is  practically  the  same.  The 
patients  are  kept  in  bed  from  eight  to  twenty-one  days  accord- 
ing to  the  size  of  the  hernia  and  the  condition  of  the  tissues. 


OPERATIONS  UPON  THE  ABDOMEN  469 

Primary  Wound  Dressiyig. — This  consists  of  sterile  gauze  covered 
with  nonabsorbent  cotton  for  the  wound  itself,  or  the  wound  may 
be  occluded  by  a  collodion  and  cotton  dressing.  A  spica  bandage 
is  applied,  the  buttocks  being  supported  by  the  Volkmann  block 
or  an  inverted  basin.  The  thighs  should  be  separated  and 
'  slightly  flexed.  If  these  precautions  are  not  taken  too  much 
traction  by  the  weight  of  the  limb  will  be  put  upon  the  recently 
sutured  wound,  and  in  addition  when  the  patient  is  placed  in 
bed  a  hiatus  will  be  present  over  the  lower  portion  of  the  wound, 
through  which  infection  can  readily  enter.  In  males  the  scrotum 
is  supported  by  placing  a  band  of  adhesive  plaster  three  inches 
broad  under  the  scrotum,  the  ends  being  fastened  to  the  anterior 
surface  of  the  thighs.  If  desirable,  as  in  children,  the  dressing  is 
protected  from  urine  by  cutting  an  aperture  in  a  foot  square  of 
rubber  protective.  This  is  slipped. over  the  penis.  In  children  or 
violent  patients  the  wound  may  be  further  protected  by  a  few 
turns  of  plaster-of -Paris  bandage.  During  the  stay  in  bed  tension 
on  the  wound  is  prevented  by  placing  a  folded  pillow  beneath  the 
knees,  and  thus  slightly  flexing  the  thighs  on  the  pelvis.  The 
dressing  is  removed  on  the  seventh  to  the  tenth  day  and  the  skin 
stitches  removed.  The  recently  healed  wound  is  protected  by  a 
gauze  compress  and  a  spica  bandage.  If  removable  cross  sutures 
of  silkworm  gut  have  been  used  these  are  removed  on  the  twelfth 
day.  On  the  eleventh  day  the  patient  sits  up  in  bed  and  on  the 
twelfth  in  a  chair.  Males  should  wear  a  suspensory  bandage  for 
three  months  following  the  operation.  No  work  involving  strain 
on  the  parts  should  be  undertaken  for  at  least  three  months.  No 
truss  should  be  worn  under  any  circumstances,  as  its  pressure 
will  cause  a  recurrence  of  the  hernia  by  stretching  and  thinning 
the  lines  of  suture.  In  case  union  is  defective  the  question  of 
the  necessity  for  a  truss  or  a  second  operation  must  be  decided 
in  the  individual  case.  Drainage  will  only  be  necessary  in 
cases  in  which  an  extensive  dissection  has  been  done,  in  which 
large  surfaces  of  loose  connective  tissue  have  been  opened  up, 
or  in  some  cases  in  which  removal  of  the  testicle  has  been  advis- 
able and  the  connective  tissue  of  the  scrotum  invaded.  Its 
purpose  is  to  provide  for  the  escape  of  the  large  amount  of  serum 
resulting  from  opening  up  large  areas  of  loose  connective  tissue. 


470  OPERATING    ROOM    AND    THE    PATIENT 

In  two  or  three  days  this  drain  is  removed.  Recurrence  depends 
upon  the  technic  employed,  the  exact  suturing,  primary  union, 
upon  the  strain  which  is  brought  upon  the  wound,  and  upon  the 
size  and  duration  of  the  hernia  and  the  age  of  the  patient.  The 
lax  tissues  and  weak  reparative  powers  of  old  age  predispose 
against  good  results.  In  no  case  can  a  cure  be  guaranteed. 
Recurrence  may  follow  in  a  few  months  or  after  a  lapse  of  years. 
Extravasation  of  blood  into  the  cellular  tissue  of  the  scrotum  occurs 
after  operations  in  which  the  loose  cellular  tissues  of  the  scrotum 
have  been  invaded,  as  in  operations  for  scrotal  hernia.  Oozing 
occurs  into  the  loose  cellular  tissues  of  the  scrotum  resulting  in 
an  ecchymosis  which  may  even  involve  the  cellular  tissue  of  the 
pelvis.  If  the  extravasation  is  extreme,  which  is  rarely  the 
case,  puncture  of  the  scrotum  at  its  dependent  portion  may  be 
necessary.  Usually  support  of  the  scrotum  with  strapping  is 
sufficient  to  cause  the  blood  to  be  absorbed  in  a  few  days.  Pro- 
phylactic measures,  as  strapping,  should  be  employed  to  prevent 
this  complication  in  cases  in  which  extensive  dissections  of  the 
loose  cellular  tissues  of  the  scrotum  are  necessary  and  drainage 
should  be  provided  for.  Ecchymosis  without  marked  extravasation 
may  occur.  The  skin  of  the  penis,  scrotum  and  surrounding  parts 
may  become  black  as  from  a  bruise.  No  treatment  is  necessary. 
Necrosis  of  the  sac  may  follow  methods  in  which  the  sac  has 
been  used  as  a  support  for  the  internal  ring,  or  in  which  the  sac 
has  been  dislocated.  This  may  be  due  to  deficient  blood  supply 
or  to  sepsis.  This  accident  is  shown  by  pain,  swelling  and  fever. 
It  will  be  necessary  to  open  the  wound  freely  and  drain.  Necrosis 
of  the  testicle  may  follow  if  the  spermatic  artery  has  been  injured, 
or  may  result  from  torsion  of  the  cord.  In  either  event  the 
affected  testicle  will  be  painful  and  will  enlarge.  There  will 
be  fever.  Opening  the  lower  angle  of  the  wound  will  allow  the 
escape  of  pus  and  some  stringy  grayish  masses  from  the  testicle. 
The  treatment  is  removal  of  the  testicle  and  free  drainage  of  the 
resulting  wound.  Orchitis  is  comparatively  frequent.  It  is  due 
to  injury  to  the  cord  at  the  operation,  or  to  pressure  upon  the 
cord  by  the  sutures.  In  either  event  it  is  not  serious.  The 
testicle  and  scrotum  may  attain  the  size  of  the  fist,  but  the 
swelling  rapidly  disappears  as  a  rule  and  demands  no  treatment 


OPERATIONS    UPON    THE    ABDOMEN  471 

other  than  the  support  afforded  by  a  suspensory.  Should 
swelling  be  persistent,  local  inunctions  of  belladonna,  ichthyol 
or  mercurial  ointment  help  somewhat,  or  the  testicle  may  be 
strapped.  Hydrocele  will  only  rarely  be  a  post-operative  com- 
plication. Phlebitis  of  the  femoral  vein  rarely  occurs  in  aseptic 
wounds. 

Difficulty  in  urination  is  more  likely  to  follow  in  males,  and  is 
due  in  part  to  reflex  inhibition.  Retention  may  result  and 
necessitate  the  use  of  the  catheter  for  a  few  days.  As  a  rule 
these  simple  cases  do  well  throughout  and  never  give  any  cause 
for  anxiety. 

Femoral  Hernia. — The  same  rules  of  dressing  apply  as  in 
inguinal  hernia.     Complications  are  rare  and  are  due  to  infection. 

Phlebitis  may  ensue  as  a  result  of  undue  pressure  from  a 
retractor  upon  the  femoral  vein  (Fabricius'  operation)  or  as  a 
result  of  infection.  In  the  former  case  it  will  be  transient  and  is 
avoidable  with  care  at  the  operation.  A  clot  may,  however, 
become  displaced  and  be  carried  to  the  heart,  causing  death. 

Umbilical  Hernia.  Ventral  Hernia. — These  forms  are  dealt 
with  as  ordinary  laparotomy  wounds,  except  that  in  long-stand- 
ing hernia  requiring  extensive  plastic  operation  the  stay  in  bed 
should  be  longer. 

Incarcerated  Hernia. — Inguinal,  Femoral,  Umbilical,  Ventral. 
In  cases  in  which  there  is  slight  damage  to  the  gut  and  few  adhe- 
sions, the  after-course  is  as  satisfactory  as  in  simple  hernise. 
Should  it  be  necessary  to  open  up  much  loose  connective  tissue, 
a  small  gauze  drain  is  used  for  two  or  three  days.  When  the 
discharge  of  serum  is  profuse  the  outer  dressing  is  changed  daily. 
Usually  aseptic  healing  rapidly  ensues  and  the  course  of  wound 
healing  is  the  same  as  in  simple  cases.  A  radical  operation  can 
usually  be  performed.  If  not,  a  supporting  pad  must  subse- 
quently be  worn.  An  enema  is  given  to  move  the  bowels  directly 
the  patient  has  recovered  from  the  anesthetic.  Small  doses  of 
magnesia  sulphate,  a  dram  of  the  saturated  solution,  are  given 
every  few  hours  to  keep  the  bowel  contents  liquid  for  the  first 
few  days. 

Complications. — These  are  rarely  due  to  infection  at  the  time 
of  operation,  but  are  due  to  the  condition  of  the  parts.     Intestinal 


472  OPERATIXG  ROOM  AND  THE  PATIENT 

toxemia.  The  patients  recover  from  the  shock  of  the  operation 
and  the  bowels  move  freely,  the  stools  being  very  foul  smelling. 
The  abdominal  pains  continue,  pulse  about  100,  temperature 
100°  to  101°  F.  There  is  neither  rigidity  nor  distention.  Treat- 
ment consists  in  repeated  enemata  to  rid  the  intestinal  tract  of 
the  toxic  products  of  putrefaction.  Ohstipation.- — The  vomiting 
stops,  the  patients  react  from  the  operation,  but  the  bowels  do 
not  move  and  the  patients  do  not  feel  well,  though  all  else  is 
favorable.  In  such  cases  enemata  will  relieve  the  distress. 
Peritonitis. — This  may  be  caused  by  the  entrance  of  the  infected 
fluid  in  the  hernial  sac  into  the  general  peritoneal  cavity.  The 
onset  will  be  immediate,  the  course  will  be  rapid  and  death  quickly 
supervenes.  Treatment. — Immediate  laparotomy'  and  drainage 
with  the  patient  in  the  elevated  head  and  trunk  position.  An 
autopsy  will  show  but  slight  changes  in  the  intestinal  loop  which 
was  the  seat  of  the  incarceration. 

Secondary  Perforation  of  the  Affected  Loop. — Following  opera- 
tion for  strangulated  hernia  in  which  intestine,  the  condition  of 
which  is  questionable,  has  been  returned  to  the  abdomen  secondary 
perforation  of  the  loop  may  occur.  Under  ordinary  circumstances 
such  suspected  intestine  would  be  resected,  but  in  some  cases 
the  condition  of  the  patient  is  such  that  prolonged  operative 
interference  is  out  of  the  question  and  one  must  return  to  the 
abdomen  intestine  the  vitality  of  which  is  questionable.  Of 
course,  if  one  was  positive  that  gangrene  would  follow  one  would 
resect  or  form  an  artificial  anus  at  first;  in  any  event  such  sus- 
picious loops  should  be  sutured  to  the  peritoneum  in  the  neigh- 
borhood of  the  wound  and  a  drain  led  to  them.  Occasionally, 
however,  gut  is  returned  which  appears  to  be  recovering  its 
normal  appearance  but  which  subsequently  undergoes  gangrene 
and  perforates. 

We  have  then  to  deal  with  two  classes  of  cases:  first,  those  in 
which  perforation  may  be  expected  and  for  which  provision  has 
been  made  at  the  time  of  operation  by  suturing  the  suspected 
loop  in  the  neighborhood  of  the  wound  and  by  drainage,  or  by 
the  formation  of  an  artificial  anus  with  the  affected  loop;  second, 
cases  in  which  the  returned  gut  is  apparently  recovering  and 
yet  later  perforates.     In  the  first  class  as  perforation  has  been 


OPERATIONS  UPON  THE  ABDOMEN  473 

expected  a  suitable  provision  has  been  made  and  providing  the 
case  survives  the  operation  recovery  may  be  expected  with  an 
artificial  anus.  In  the  second  class  of  cases  a  normal  course 
may  be  followed  for  twenty-four  or  forty-eight  hours,  the  bowels 
may  move  and  recovery  be  confidently  expected,  when  suddenly 
there  occur  abdominal  pain  and  collapse  with  evidence  of  a 
rapid  peritonitis,  the  picture  of  a  perforation  without  adhesions. 
Treatment  will  probably  be  of  no  avail.  However,  the  abdomen 
should  be  immediately  opened,  either  the  gut  resected,  or  pref- 
erably an  artificial  anus  made,  the  peritoneal  cavity  cleansed 
and  the  elevated  head  and  trunk  posture  employed.  Perfora- 
tion may  be  preceded  by  the  formation  of  sufficiently  strong 
adhesions  to  allow  of  abscess  formation.  Such  cases  usually 
recover  as  the  site  of  perforation  is  apt  to  be  in  the  neighborhood 
of  the  wound  and  the  abscess  may  point  into  the  wound  or  be 
opened  through  the  wound  when  evidences  of  this  condition 
(septic  temperature,  clulness  and  tenderness)  present  themselves. 
Should  these  symptoms  occur  the  wound  is  to  be  carefully  opened 
and  the  fecal  abscess  evacuated.  The  opening  of  such  an 
abscess  should  not  be  delayed  in  the  hope  that  stronger  adhesions 
will  form,  as  intestinal  adhesions  surrounding  fecal  abscesses 
rarely  become  very  firm,  and  if  opening  of  the  abscess  is  delayed 
these  weak  adhesions  may  be  broken  down  by  the  tension  of  the 
accumulation.  On  account  of  the  weak  nature  of  these  adhe- 
sions these  abscesses  should  be  opened  very  carefully  in  order 
to  avoid  soiling  the  peritoneal  cavity.  Suitable  drainage,  at 
first  gauze,  should  be  gently  inserted;  this  should  be  changed 
twice  daily  and  in  two  or  three  days  when  the  adhesions  are 
stronger,  a  soft  rubber  drainage  tube  is  inserted.  The  outer 
dressings  are  changed  every  two  or  three  hours.  Phlegmon  of 
the  abdominal  wall  or  gravitation  abscesses  may  complicate 
wounds  of  this  character. 

Paresis  of  the  Affected  Loop. — At  the  operation  the  intestine 
may  apparently  recover  its  tone  and  be  returned  to  the  abdo- 
men, yet  the  symptoms  of  obstruction  persist,  vomiting  con- 
tinues, meteorism  is  extreme  and  collapse  and  death  follow  in 
from  twenty-four  to  forty-eight  hours.     At  autopsy  the  affected 


474  OPERATING    ROOM    AND    THE    PATIENT 

portion  of  the  gut  is  found  dilated.  This  is  due  to  a  paresis 
occurring  at  the  site  of  obstruction. 

The  same  symptoms  will  persist  and  be  due  to  mechanical 
conditions  -^-hen  reduction  en  masse  has  occurred.  In  reduction 
en  masse  forced  taxis  causes  a  separation  of  the  peritoneum 
from  the  abdominal  wall  and  the  whole  sac  is  separated  from 
its  coverings  and  forced  between  the  peritoneum  and  the  ab- 
dominal wall  with  its  contents  still  unreduced,  forming  a 
peritoneal  hernia.  If  a  hernia  is  reduced  en  masse  the  gurgling 
sound  heard  in  hernia  properly  reduced  is  not  noted.  Adhe- 
sions may  also  keep  up  the  obstruction  even  after  the  hernial 
contents  have  been  reduced. 

Treatment. — In  cases  of  paresis  following  operations  for 
obstruction  a  secondary  laparotomy  should  be  undertaken  and  an 
artificial  anus  made  above  the  affected  loop.  In  cases  of  hernia 
in  which  symptoms  of  obstruction  persist  after  apparent  reduc- 
tion an  immediate  exploratory  laparotomy  should  be  made. 

Stenosis  of  the  intestine  may  occur  some  months  following 
operation  for  strangulated  hernia.  The  stenosis  occurs  at  the 
site  of  the  previous  strangulation  and  is  caused  by  a  cicatricial 
contraction  of  a  gangrenous  area  in  the  mucous  membrane. 

General  Treaiment. — In  cases  not  resected  the  diet  should 
be  fluid  for  the  first  few  days,  and  the  contents  of  the  small 
intestine  kept  liquid  by  giving  dram  doses  of  sulphate  of 
magnesia  every  few  hours.  In  resection  cases  water  is  given  as 
soon  as  anesthetic  vomiting  ceases,  other  fluids  in  twenty- 
four  hours  and  soft  diet  after  the  fourth  day,  following  which 
other  foods  are  added.  The  bowels  are  moved  with  enemata 
in  the  case  of  small  intestinal  wounds.  In  wounds  of  the  large 
intestine  enemas  are  contraindicated;  small  doses  of  dilute 
magnesium  sulphate  every  two  or  three  or  four  hours  being 
given  to  ensure  the  liquid  condition  of  the  bowel  contents.  The 
dose  of  magnesium  sulphate  must  not  be  sufficient  to  produce 
purgation.  Under  this  treatment  collection  of  fecal  masses  in 
the  colon  is  avoided. 

Wound  Treatment. — If  the  wound  is  completely  sutured  the 
treatment  is  the  same  as  any  aseptic  woimd.  If  a  drain  has 
been  led  down  to  the  affected  loop  to  afford  an  outlet  in  case  of 


OPERATIONS    UPON    THE    ABDOMEN  475 

leakage  or  perforation  this  should  be  removed  at  the  end  of 
forty-eight  hours;  if  the  gauze  comes  away  clean  it  should  be 
replaced  by  a  small  strip  leading  down  to  the  peritoneum  which 
is  removed  but  not  renewed  at  the  end  of  twenty-four  hours. 
If  leakage  occurs  as  shown  by  the  telltale  drainage  strip  it  will 
follow  the  course  of  the  provisional  drain.  Leakage  requires 
enlargement  of  the  drainage  opening  and  the  gentle  insertion  of  a 
tube  if  retention  is  present. 

Following  Murphy  button  operations  the  button  usually  passes 
in  nine  to  eighteen  days  but  may  be  delayed  a  great  deal  longer. 
Radiography  will  show  its  change  of  position.  The  button  may 
pass  as  far  as  the  rectum  and  become  lodged  there.  In  this 
event  the  patient  will  complain  of  rectal  irritation.  Digital 
examination  will  result  in  its  discovery  and  removal.  Occa- 
sionally the  button  will  not  pass  into  the  large  intestine  and 
will  require  removal  by  secondary  operation.  Obstruction  at 
the  site  of  the  button  occasionally  occurs. 

Operations  Upon  the  Liver.  Abdominal  Hepatotomy. — The 
treatment  of  cysts  and  abscesses.  A  biliary  fistula  may  persist. 
So  long  as  the  flow  of  bile  is  not  excessive,  this  need  not  oc- 
casion alarm.  Repeated  packing  with  gauze  will  usually  effect 
a  cure.     If  not  the  thermocautery  may  be  employed. 

Transpleural  Hepatotomy  for  Cysts  and  Abscess. — In  such  opera- 
tions care  must  be  taken  to  avoid  infection  of  the  pleural  cavity. 
This  is  best  done  by  suturing  and  gauze  packing  before  opening 
the  liver  substance. 

Hepatotomy  for  Stone. — Keep  the  parts  aseptic  until  the  stones 
lodged  in  the  intrahepatic  bile  ducts  have  escaped,  then  treat  as 
an  hepatic  biliary  fistula. 

Hepatectomy. — ^For  whatever  cause  this  operation  is  per- 
formed the  after-treatment  is  the  same.  Four  things  are  to  be 
guarded  against:  excessive  oozing,  secondary  hemorrhage,  the 
escape  of  bile,  and  the  extension  of  the  localized  peritonitis 
which  occurs  after  these  operations.  Oozing  and  secondary  hem- 
orrhage are  prevented  by  accurate  hemostasis  at  the  time  of  the 
operation  by  means  of  circumsuture  of  the  larger  vessels  suturing 
raw  surfaces  in  apposition  and  where  this  is  impossible  thermo- 
cauterization  of  the  raw  surfaces.     These  measures  also  lessen 


476  OPERATING    ROOM    AND    THE    PATIENT 

the  discharge  of  bile  after  operation.  Should  the  raw  surface 
be  large,  it  is  advisable  to  fix  it  to  the  abdominal  wall  in  the 
neighborhood  of  the  wound.  This  permits  firm  packing  against 
the  oozing  surface  and  obviates  the  risk  of  respiratory  movements 
interfering  with  the  efficiency  of  the  packing.  The  packing  is 
allowed  to  remain  in  place  for  from  forty-eight  to  seventy-two 
hours  and  is  then  very  carefully  removed  and  replaced  by  a 
smaller  packing.  Should  secondary  hemorrhage  occur,  the 
packing  is  to  be  renewed,  and  should  this  fail  to  arrest  the  bleed- 
ing, the  abdominal  wound  is  to  be  reopened  and  the  bleeding 
surface  fixed  in  the  wound.  This  brings  the  bleeding  area  under 
absolute  control  and  its  treatment  by  circumsuture  or  thermo- 
cauterization  is  rendered  easy.  The  packing  is  renewed  every 
forty-eight  hours  until  the  liver  wound  is  covered  with  granula- 
tions, when  dressing  may  be  done  every  third  day.  No  irriga- 
tion is  to  be  employed  as  adhesive  inflammation  occurs  very 
slowly  if  there  is  any  leakage  of  bile.  The  escape  of  bile  will 
usually  be  slight  if  thermocauterization  has  been  thorough. 
Should-  a  persistent  biliary  fistula  follow,  tamponade  with  plain 
gauze  will  usually  suffice  for  its  cure.  The  thermocautery  may 
also  be  employed.  The  danger  of  spreading  peritonitis  from 
the  escape  of  bile  is  slight.  The  bile  will  follow  the  gauze  and 
no  more  than  a  localized  peritonitis  will  result. 

Hepatopexy. — The  after-treatment  is  as  for  laparotomy  in 
general.  The  patient  should  remain  in  bed  for  two  weeks,  and 
should  wear  a  supporting  binder  for  at  least  a  year  after  the 
operation.     Properly  fitting  corsets  should  be  advised. 

Operations  upon  the  Gall-bladder  and  Ducts. — Tlie  after-treat- 
ment of  cases  recpiring  these  operations  is  important.  It  must 
be  remembered  that  operations  upon  the  gall-bladder  and  bile- 
ways  are  performed  for  the  relief  of  symptoms  and  that  the 
cause  of  the  conditions  present  may  not  be  permanently  influ- 
enced by  the  operation. 

A  thorough  and  efficient  course  of  t-reatment  looking  to  the 
cure  of  the  cause  should  be  instituted.  Gall-stones  can  rarely 
be  expelled  by  the  action  of  cholagogues  and  are  never  dissolved 
by  the  action  of  Carlsbad  water.  What  the  Carlsbad  sprtidel 
salts  do  accomplish  is  to  relieve  the  acute  inflammatory  proc- 


OPERATIONS  UPON  THE  ABDOMEN  477 

esses  which  occasion  the  distress,  and  so  the  disease  becomes  . 
latent.  Rarely  do  any  but  small  stones  pass  as  a  result  of  the 
treatment.  Patients  who  have  passed  stones  before  treat- 
ment may  continue  to  pass  them  irrespective  of  the  treatment 
employed.  Unless  the  stones  are  removed  by  operation,  attacks 
are  liable  to  recur  from  time  to  time.  On  the  other  hand,  by 
removing  the  stones  and  enforcing  a  rigid  after-treatment,  a 
possible  recurrence  will  be  avoided.  Operations  performed 
while  the  stones  are  yet  in  the  gall-bladder,  give  the  best  results 
and  afford  the'  greatest  freedom  from  recurrence.  Surgeons  for 
the  most  part  believe  that  recurrences  are  the  result  of  stones 
overlooked  at  the  operation.  Patients  should  be  placed  in  as 
good  hygienic  surroundings  as  their  resources  will  admit.  All 
patients  can  secure  the  simple  articles  of  food  which  are  of  bene- 
fit in  their  condition,  and  can  afford  to  purchase  the  artificial 
■Carlsbad  spriidel  salt.  T1t£  amount  of  meat  and  alcohol  should 
be  limited. 

Cholecystostomy. — Accessory  drainage,  split  tube  and  gauze 
strips  are  removed  on  the  fourth  or  fifth  day  and  the  resulting 
sinus  allowed  to  heal.  The  tube  draining  the  gall-bladder  is 
allowed  to  remain  in  place  at  least  until  protecting  adhesions 
have  formed  around  it  and  a  drainage  tract  has  been  formed. 
This  will  prevent  peritonitis  from  the  escape  of  bile  and  infective 
material  into  the  general  peritoneal  cavity.  After  ten  days  the 
tube  is  removed  for  purposes  of  cleansing.  If  more  prolonged 
drainage  is  indicated,  i.e.,  if  the  stools  have  not  resumed  their 
normal  color,  or  if  the  normal  colored  bile  has  not  passed 
through  the  tube,  the  tube  is  replaced  and  only  removed  at 
intervals  of  several  days  for  cleansing.  The  flow  of  bile  or 
muco-pus  will  continue  until  the  condition  of  the  gall-bladder 
and  ducts  approaches  normal.  Following  the  removal  of  the 
tube  the  resulting  fistula  usually  closes  in  from  a  few  days 
to  six  weeks.  The  operative  procedure  which  allows  of 
quickest  closure  consists  in  suturing  a  half-inch  rubber  tube 
into  the  gall-bladder  incision.  Two  purse-strings  are  placed  in 
the  gall-bladder  wall  surrounding  the  tube.  Pressure  on  the 
tube  causes  inversion  of  the  gall-bladder  wall.  The  purse- 
strings  are  now  tied  down  securing  the  tube  in  position.     Plain 


478  OPERATIXG    ROOM    AXD    THE    PATIENT 

catgut  is  used  for  the  tube  sutures,  chromic  catgut  for  the  purse- 
strings.  Upon  removal  of  the  tube  there  is  no  eversion  of 
mucous  membrane  consequently  more  rapid  healing  ensues. 
The  stools  are  watched,  as  by  observing  them,  an  idea  is  gained 
of  the  condition  present  in  the  common  or  hepatic  ducts.  When 
the  stools  regain  their  normal  color  it  means  that  the  catarrhal 
inflammation  or  the  conditions  producing  an  acute  obstruction 
have  subsided  and  drainage  may  be  dispensed  ^^•ith.  If,  how- 
ever, the  stools  remain  light  after  a  lapse  of  time  sufficient  to 
allow  of  the  subsidence  of  acute  inflammation  search  must  be 
made  for  the  cause  of  the  obstruction.  This  may  be  the  result  of 
sufficient  traumatism  having  been  inflicted  on  the  common  bile 
duct,  or  in  rarer  cases,  the  hepatic  duct,  by  the  passing  of  stones  to 
have  led  to  the  formation  of  a  cicatricial  stenosis;  or  the  gall- 
bladder may  have  been  improperely  fastened  to  the  abdominal 
wall  or  a  stone  may  have  been  overlooked;  or  a  malignant  stenosis 
of  the  common  duct  may  obtain.  In  order  to  determine  the 
point  and  character  of  the  obstruction  a  close  study  must  be 
made  not  only  of  the  stools  but  of  the  amount  of  bile  which  is 
discharged  through  the  tube,  and  of  the  general  symptoms. 
Should  the  obstruction  be  due  to  calculus  in  the  he^^atic  duct  or 
disturbance  of  the  bile  producing  function  in  the  liver  by  malig- 
nant disease  of  that  organ  involving  the  hepatic  duct,  bile  will 
pass,  if  at  all,  in  only  small  cpantities  either  through  the  fistula  or 
through  the  common  duct  into  the  duodenum.  The  stools  will 
be  slightly  if  any  colored.  Jaundice  will  be  extreme.  If  the 
obstruction  be  due  to  an  impacted  calculus  or  to  cicatricial  con- 
traction or  to  malignant  disease  of  the  common  duct,  the  stools 
will  remain  light  colored  and  the  discharge  of  bile  through  the 
fistula  will  be  profuse.  Should  the  obstruction  be  caused  by  a 
kinking  of  the  common  bile  duct  due  to  a  malposition  of  the 
gall-bladder,  this  ma}'  be  determined  by  blocking  up  the  tube 
or  fistula  b}'  plugging  it  with  cotton  or  a  wooden  plug  and  cotton 
combined;  if  due  to  kinking  of  the  common  duct,  the  distention 
of  the  gall-bladder  by  the  accumtdating  bile  will  produce  a  dilated 
condition  of  the  cystic,  hepatic  and  common  bile  duct  which 
will  result  in  a  straightening  of  the  latter  so  that  the  kinking 
will    be    temporarily    overcome    and    bile    will    appear    in    the 


OPERATIONS  UPON  THE  ABDOMEN  479 

stools.  Should  the  cause  not  be  kinking  but  actual  obstruc- 
tion, no  bile  will  be  found  in  the  stools.  Should  a  ball-valve 
stone  be  lodged  in  the  common  duct  it  may  happen  that 
the  coloring  of  the  stools  will  be  intermittent  and  the  amount 
of  bile  discharged  through  the  tube  or  fistula  will  vary  accord- 
ingly. The  removal  of  the  stone  is  indicated  by  choledocho- 
tomy  or  duodenotomy  if  the  stone  is  found  in  the  ampulla 
of  Vater.  Should  the  cystic  duct  be  obstructed  by  stone  or 
cicatricial  contraction  or  persistent  catarrh  no  bile  will  flow 
from  the  tube  but  only  the  secretion  of  the  gall-bladder  itself, 
mucus  or  muco-pus.  The  stools  will  be  of  normal  color.  With 
the  exception  of  kinking,  the  result  of  imperfect  techmc,  or 
cicatricial  stenosis  which  may  supervene  at  any  time  as  a  result 
of  traumatism,  the  causes  of  complicating  obstruction  should 
have  been  diagnosed  or  at  least  suspected  by  the  digital  ex- 
amination of  the  parts  at  the  time  of  operation.  No  time  is 
to  be  lost  in  ascertaining  the  cause  and  promptly  removing  it. 
Should  this  be  found  impossible  a  cholecystenterostomy  must  be 
performed. 

Primary  Dressing. — The  wound  is  covered  with  plain  gauze 
covered  with  rubber  protective  to  prevent  eczema  and  disturb- 
ances of  wound  healing  due  to  the  irritating  effects  of  the 
infected  bile.  The  end  of  the  tube  is  connected  with  a 
longer  tube  the  end  of  which  is  submerged  in  a  bottle  of 
bichlorid  suspended  at  the  side  of  the  bed  (subaqueous  drainage) . 
This  also  allows  of  an  estimate  of  the  amount  of  bile  passed. 
If  the  wound  dressing  becomes  soiled  it  is  to  be  immedi- 
ately changed.  If  asepsis  has  been  successfully  maintained, 
the  wound  dressing  is  not  changed  until  the  fourth  day 
when  the  accessory  drain  usually  used  is  removed.  A  light 
repacking  of  the  point  of  emergence  is  all  that  is  necessary.  On 
the  seventh  day  the  sutures  are  removed.  Should  bile  escape 
alongside  the  tube  the  dressings  are  changed  as  soiled.  The  care 
of  the  tube  has  been  indicated.  When  its  period  of  usefulness 
has  passed,  i.e.,  when  discharge  of  bile  is  reduced  to  a  small 
amount  daily  it  is  removed.  The  elevated  head  and  trunk 
position  is  used  for  the  first  forty-eight  hours,  after  which  the 
bed  is  leveled  and  the  patient  propped  up  in  bed.     He  may  get 


480  OPERATING    ROOM    AND    THE    PATIENT 

out  of  bed  when  the  gall-bladder  tube  is  removed.  When  the 
patient  sits  up  in  bed  the  subaqueous  drain  is  dispensed  with 
and  the  end  of  the  gall-bladder  tube  placed  in  a  six  ounce  bottle 
which  is  attached  to  the  binder  by  tape  and  safety-pins. 

There  may  be  considerable  temperature  reaction  after  drainage 
operations  in  this  region.  This  reaction  is  lessened  by  employing 
the  elevated  head  and  trunk  position  or  the  sitting  posture. 
This  also  makes  the  patient  more  comfortable  by  relieving 
pressure  on  the  diaphragm  and  so  rendering  respiration  easier. 

Biliary  Fistulce  which  Persist  even  after  the  Stools  have  become 
the  Normal  Color. — Such  fistulse  may  discharge  mucus  alone  or 
in  addition  a  small  amount  of  bile.  The  reason  for  their  remain- 
ing open  will  be  found  in  eversion  of  the  mucous  membrane  of 
the  gall-bladder  which  has  grown  into  the  fistula  or  in  obstruc- 
tion of  the  cystic  duct.  In  the  first  instance  the  use  of  the 
thermocautery  may  close  the  fistula  by  destroying  its  walls  and 
the  evert-ed  mucous  membrane.  This  failing,  the  fistulous  tract 
is  dissected  out  in  its  entirety  and  the  opening  into  the  gall- 
bladder closed.     In  the  latter  case,  cholecystectomy  is  indicated. 

Operations  upon  Jaundiced  Patients. — Hemostasis  must  be 
exact.  Such  patients  bleed  easily  and  at  times  lose  such  an 
amount  of  blood  through  mere  oozing  that  death  ensues.  Cal- 
cium lactate  may  be  administered  in  ten  grain  doses  every  four 
hours  and  three  ounces  of  human  or  horse  serum  administered 
hypodermically  each  day. 

Cholecystotomy. — If  this  "ideal"  operation  is  performed 
strictly  according  to  the  indications,  there  should  be  no  resulting 
complications.  But  even  when  all  the  stones  are  in  the  gall- 
bladder, and  no  inflammatory  symptoms  are  present  the  trauma- 
tism incident  to  the  removal  of  the  stone  or  stones  may  be  suffi- 
cient to  set  up  a  catarrh  of  the  gall-bladder.  This  if  communi- 
cated to  the  ducts  might  work  disastrous  consequences.  If  but 
one  large  stone  be  present,  the  probability  of  a  successful  issue 
is  excellent,  but  if  more  than  one  are  present,  the  operator  can- 
not be  quite  sure  whether  all  the  stones  have  been  removed  or 
not  so  the  after-course  of  the  case  will  be  watched  with  greatest 
anxiety.  The  operation  precludes  a  thorough  examination  of 
the  gall-bladder  and  ducts  on  account  of  the  danger  of  trauma- 


OPERATIONS  UPON  THE  ABDOMEN  481 

tism  as  cited  above.  Should  a  provisional  drain  be  employed 
leading  to  the  line  of  sutures  in  the  gall-bladder,  this  is  removed 
on  the  fourth  day  if  no  leakage  has  occurred.  If  leakage  does 
occur,  a  rubber  drainage  tube  must  be  introduced  surrounded 
with  gauze  to  prevent  peritoneal  infection.  The  treatment  of 
the  case  subsequent  to  leakage  is  as  for  cholecystostomy. 

Cholecystectomy. — If  the  mucous  membrane  of  the  cut  end 
of  the  cystic  duct  has  been  destroyed  by  the  thermocautery 
no  fistula  will  follow.  The  after-treatment  is  as  for  wounds  of 
the  liver.  The  cystic  duct  may  become  dilated  after  a  lapse  of 
time  and  partially  compensate  for  the  loss  of  the  bladder.  This 
has  been  observed  in  experiments  upon  dogs. 

Cholecystenterostomy. — The  telltale  drain  is  removed  on  the 
fourth  day  and  if  there  has  been  no  leakage  is  not  replaced. 
Leakage  calls  for  enlargement  of  the  drainage  opening  and  the 
employment  of  tube  and  gauze  drainage.  Ascending  infection 
of  the  bile  ducts  and  liver  from  intestinal  bacteria  may  occur  at 
any  time. 

Choledochostomy. — Accessory  drains  are  removed  on  the 
fourth  day.  The  small  rubber  tube  draining  the  duct  is  removed 
on  the  following  day  or,  if  very  extended  drainage  is  desired, 
on  the  tenth  day. 

Choledochotomy. — If  there  is  no  leakage  the  telltale  drain  is 
removed  on  the  fourth  day.     Leakage  requires  tube  drainage. 

In  the  various  other  plastic  operations  upon  the  ducts  the 
same  rules  apply. 

Operations  Upon  the  Spleen.  Splenotomy  for  Abscess.- — The 
wound  is  firmly  but  gently  tamponed  to  guard  against  hemor- 
rhage. The  tamponade  is  removed  on  the  fourth  day  and  the 
cavity  lightly  repacked  every  second  day.  No  irrigation  should 
be  used  for  fear  of  setting  up  bleeding.  Large  masses  of  splenic 
tissue  will  slough.  These  should  not  be  removed  forcibly  but 
should  be  allowed  to  separate  themselves.  Sepsis  is  a  common 
complication.  Secondary  hemorrhage  is  always  imminent.'  The 
condition  of  the  patient  from  the  time  the  lesion  is  recognized  is, 
as  a  rule,  such  as  to  preclude  any  major  operative  procedure 
such  as  splenectomy.  With  great  care  and  gentleness  in  the 
management  of  the  wound  an  occasional  case  will  be  saved. 

31 


482  OPERATING    ROOM    AXD    THE    PATIENT 

Splenopexy . — These  patients  should  be  kept  in  bed  for  four 
T\-eeks,  and  should  recline  for  the  most  part  on  the  left  side, 
A  supporting  binder  should  be  worn  for  three  months.  Corsets 
affording  proper  support  should  be  advised. 

Splenectomy. — The  after-course  is  usually  uneventful  unless 
the  disease  for  which  the  operation  is  done  was  accompanied  by 
prolonged  anemia.  Secondary  hemorrhage  is  apt  to  occur  if 
the  pedicle  was  ligated  en  masse,  or  if  the  ligature  was  applied 
while  the  pedicle  was  tense.  It  is  caused  by  retraction  of  the 
tissues  following  relief  of  the  tension.  The  treatment  is  im- 
mediate operation  with  more  exact  hemostasis.  In  those  pa- 
tients already  suffering  from  severe  anemia  blood  transfusion  is 
essential  to  success. 

Thrombosis  of  the  Splenic  Vein. — The  thrombus  may  extend 
into  the  superior  or  inferior  mesenteric  vein  or  both  and  com- 
pletely or  partially  occlude  the  vessels.  Recovery  has  been 
reported  (Summers)  following  secondary  laparotoni}'  with  in- 
folding of  the  gangrenous  intestinal  areas  and  drainage.  The 
prevention  would  seem  to  be  more  gentle  operative  manipula- 
tion of  the  pedicle.  The  symptoms  are  those  of  shock,  ab- 
dominal pain  and  vomiting.  The  possibility  of  the  complica- 
tion should  always  be   borne  in  mind  (Delatour). 

Transabdominal  Operations  upon  the  Kidney  (Large  Cysts, 
Tumors,  Hypernephroma). — The  after-care  combines  that  of 
laparotomy  with  that  of  extraperitoneal  operations  upon  the 
kidney. 

Operations  upon  the  Pancreas. — The  care  of  the  wound  resolves 
itself  Into  the  care  of  the  tubing  and  packing  which  have  been 
used  for  purposes  of  drainage  and  for  controlling  hemorrhage. 
The  amount  of  drained  material  will  be  greater  by  the  lumbar 
than  by  the  anterior  route  and  will  rec|uire  more  frecpent  change 
of  outer  dressings.  The  wound  dressing  itself  is  left  undisturbed 
until  the  fourth  clay  unless  high  temperature  develops  traceable 
to  damming  back  of  secretions. 

Post-operative  hemorrhage  from  the  pancreatic  artery  and 
neighboring  blood-vessels  is  frequent  following  operation  in  the 
stage  of  abscess  formation  and  necrosis.  These  hemorrhages 
are  severe  and  usually  occur  in  the  second  week  after  the  opera- 


OPERATIONS    UPON    THE    ABDOMEN  483 

tion.  They  are  generally  fatal.  The  only  possible  treatment 
is  tamponade  as  the  necrotic  condition  of  the  pancreas  renders 
recognition  of  individual  vessels  impossible.  The  hemorrhage 
results  from  erosion  of  the  vessels.  Frequent  small  hemorrhages 
have  also  been  noted.  Early  operation  before  the  stage  of  necro- 
sis and  abscess  formation  does  not  entirely  obviate  the  danger 
of  hemorrhage. 

Thrombosis  of  the  large  venous  channels,  mesenteric  and 
splenic,  with  consequent  sequellse  such  as  metastatic  abscess  in 
the  spleen  occur. 

Pancreatic  fistula  has  a  tendency  to  heal  spontaneously  but 
healing  is  much  prolonged,  from  two  to  seven  and  a  half  months, 
and  is  not  influenced  by  diet.  The  post-operative  course  of 
lumbar  incisions  is  very  tedious.  By  either  route  done  in  the 
stage  of  abscess  formation  there  will  be  considerable  discharge 
of  small  pieces  of  necrotic  fat  and  in  some  cases  large  pieces 
of  the  pancreas.  As  complications  of  the  lumbar  incision, 
hernia  of  the  colon  through  the  wound  has  been  noted  and  also 
fecal  fistula  of  this  portion  of  the  intestine.^ 

Fifty  per  cent,  of  the  cases  show  disease  of  the  gall-bladder  in 
addition.  If  this  receives  operative  treatment  the  post-operative 
care  of  such  a  wound  is  added  to  that  of  the  pancreatic  wound. 

The  mortality  of  operations  upon  the  pancreas  for  acute 
lesions  is  60  per  cent. 

Recurrence  of  the  disease  after  operation  requiring  a  second 
operation  has  been  noted  (Beck,  Bardenheuer,  Porter,  Haenel). 

When  a  patient  has  sufficiently  recovered  a  course  of  treat- 
ment should  be  given  such  as  that  at  Carlsbad,  Vichy,  Neuenahr 
and  Hamburg.  Pawlow  has  shown  that  sodium  solution  mark- 
edly influences  the  activity  of  the  gland.  In  the  few  cases 
which  the  author^  has  had  the  course  of  convalescence  has  been 
apparently  influenced  by  starvation  of  the  patient  for  forty- 
eight  hours  following  operation.  Patients  have  been  placed  in  a 
room  by  themselves  and  with  as  perfect  rest  as  may  be  obtain- 
able. All  mention  of  food  or  food  odors  have  been  withheld  for 
forty-eight  hours,  not  even  water  being  administered  by  mouth 

^  Korte,  Annals  of  Surgery,  Iv.  p.  23. 

^L.  I.  MedicalJournal,  vol.  ii,  1908,  p.  393. 


484  OPERATIXG    ROOM    AND    THE    PATIEXT 

with  the  idea  that  complete  digestive  rest  would  predispose  to 
earlier  resolution  of  the  pancreatic  wound.  Fluid  has  been 
furnished  by  repeated  saline  enemata. 

Abdominal  Cysts. — Occasionally  cysts  are  encountered  which 
it  is  not  advisaljle  to  extirpate  on  account  of  the  difficulties  and 
dangers  attendant  on  such  a  procedure,  for  example,  adherent 
serous,  chjdous,  blood,  dermoid  and  echinococcus  cysts  of  the 
mesentery  or  abdominal  or  pelvic  viscera.  In  such  cases  the 
cyst  wall  is  attached  by  suture  to  the  abdominal  wall,  and  either 
opened  immediately  or  after  forty-eight  hours  have  elapsed  to 
allow  of  the  formation  of  protecting  adhesions.  This  latter 
constitutes  essentially  an  extraperitoneal  operation  and  almost 
certainly  precludes  the  occurrence  of  peritonitis  through  perit- 
oneal contamination  by  cyst  contents.  On  account  of  the 
large  surface  of  the  lining  of  the  sac,  in  many  instances  a  secret- 
ing membrane,  and  the  impossibility  of  efficient  drainage,  asepsis 
is  particularly  difficult  to  maintain.  Healing  occurs  by  shrink- 
age and  collapse  of  the  sac  wall.  This  latter  is  hastened  by 
intraabdominal  pressure.  Should,  however,  the  healing  process 
proceed  too  cpickly  adhesions  will  form  between  adjacent  folds 
of  the  sac  and  pockets  result.  Fortunately,  if  such  an  accident 
happens,  it  will  be  easier  for  the  retained  secretions  to  find  an 
escape  through  the  recently  formed  adhesions  than  through  the 
sac  wall.  Nevertheless,  pocketing  is  to  be  avoided  as  much  as 
possible.  When  shrinkage  is  complete,  the  sac  cavity  is  oblit- 
erated and  the  fistulous  opening  in  the  abdominal  wall  closes 
readily  as  a  rule.  The  process  occupies  from  three  to  six  weeks, 
unless  infection  has  supervened,  when  a  much  longer  time  may 
elapse  before  healing  is  complete.  Wound  Treatment. — The  most 
efficient  drainage  is  obtained  by  a  combination  of  a  thick-walled' 
rubber  tube,  one  inch  in  diameter,  through  which  is  introduced 
enough  sterile  gauze  to  loosely  fill  the  cavity.  This  prevents  too 
rapid  collapse  and  the  subsecpent  formation  of  pockets.  ■  It 
does  not  interfere  at  all  with  the  shrinkage  of  the  sac.  The 
rubber  drainage  tube  should  not  extend  more  than  a  short  dis- 
tance into  the  sac  cavity.  It  must  not  press  against  the  oppo- 
site wall  of  the  sac  or  necrosis  and  perforation  may  ensue.  A 
short  glass  tube  with  a  wide  flange  to  prevent  it  slipping  into 


OPERATIONS  UPON  THE  ABDOMEN  485 

the  sac  cavity  may  be  employed.  If  of  rubber  the  tube  is  held 
in  place  by  a  large  safety-pin  passed  through  its  wall.  To  the 
pin  is  fastened  a  tape  which  is  tied  around  the  body  or  fastened 
with  adhesive  plaster.  The  flanged  glass  tube  will  be  found 
more  comfortable.  The  purpose  of  the  tube  is  twofold,  to  keep 
the  fistulous  tract  leading  into  the  sac  cavity  dilated  until  com- 
plete closure  of  the  sac  is  effected  and  to  provide  drainage  for 
the  sac  secretions.  It  is  not  removed,  except  for  cleansing, 
until  complete  closure  of  the  sac  has  occurred,  although  it  may 
be  shortened  somewhat  or  a  shorter  tube  introduced  in  its 
place  as  healing  progresses.  It  also  acts  as  a  safety  valve 
in  case  pockets  have  been  formed.  The  loose  gauze  packing 
is  removed  at  the  end  of  forty-eight  hours  and  a  smaller 
amount  of  gauze  introduced.  This  gauze  is  changed  twice  daily, 
once  daily  or  every  other  day  according  to  the  amount  of  secre- 
tion until  complete  closure  is  effected.  Plain  gauze  fulfils  every 
indication  and  promotes  the  formation  of  granulations.  At  each 
dressing  a  smaller  quantity  of  gauze  is  introduced  yari  passu 
with  the  decrease  in  the  size  of  the  cavity.  The  outer  gauze 
dressings  are  changed  as  frequently  as  soiled.  Drainage  will  be 
facilitated  here,  as  in  empyema  cases,  by  frequently  changing 
the  position  of  the  patient.  Should  infection  supervene  in 
spite  of  every  precaution,  disinfecting  measures  must  be  in- 
troduced. Irrigating  will  be  found  the  most  efficient  of  these. 
According  to  the  amount  of  the  discharge  and  the  virulence  of 
the  infection,  the  cavity  may  be  irrigated  with  saline  or  boro- 
salicylic  solution  once,  twice  or  thrice  daily,  the  gauze  packing 
being  renewed  at  each  irrigation.  The  employment  of  stronger 
antiseptics  is  hardly  justifiable,  as  they  tend  to  increase  the 
necrosis  of  the  sac  wall,  and  from  such  a  necrosis,  perforation 
and  peritonitis  may  result.  Prolonged  suppuration  here,  as 
elsewhere,  will  cause  great  deterioration  in  the  health  of  the  pa- 
tient, and  may  even  result  in  death.  Asepsis  must  be  rigid 
throughout  the  entire  course  of  wound  healing.  After  removal 
of  the  tube,  the  resulting  fistula  is  stimulated  to  promote  more 
rapid  closure. 

Echinococcus  cysts  are  treated  on  the  same  principle  as  other 
cysts,  but  in  order  to  effect  a  cure  the  sac  lining  containing  the 


486  OPERATING    ROOM    AND    THE    PATIENT 

echinococcus  booklets  must  be  either  removed  or  destroyed. 
This  latter  is  not  surely  effected  by  shrinkage  of  the  sac,  and 
the  introduction  of  chemicals  of  sufficient  strength  to  destroy  the 
lining  membrane  is  dangerous.  The  procedure  which  has  met 
with  greatest  success  consists  in  the  gradual  separation  of  the 
mother  sac  from  its  fibrous  capsule  by  allowing  a  stream  of  saline 
solution  to  flow  between  them.  Some  seven  to  fourteen  days 
may  be  occupied  by  this  procedure,  the  mother  cyst  being  gently 
and  gradually  separated  until  finally  it  is  entirely  removed.  It 
is  preferable  to  accomplish  this  gradually  rather  than  quickly, 
especially  in  echinococcus  cyst  of  the  liver,  in  order  to  avoid  a 
biliary  fistula.  A  rapid  shrinkage  of  the  fibrous  capsule  follows. 
The  cavity  is  irrigated  daily  with  mild  iodin  solution.  Should 
calcification  occur  in  the  cyst  lining,  the  calcareous  deposits  must 
be  removed  with  a  sharp  curette,  or  healing  will  be  greatly 
prolonged  and  a  persistent  fistula  result. 

Exploratory  Laparotomy. — If  the  abdominal  cavity  is  opened 
and  its  contents  explored  without  disturbing  adhesions  or 
inflicting  injury  to  the  peritoneal  surfaces,  the  after-course  of 
the  case  will  not  give  any  cause  for  anxiety.  On  the  other 
hand,  if  in  the  course  of  the  exploration  extensive  adhesions  are 
disturbed  or  a  tumor  partly  enucleated,  the  outlook  is  more 
grave.  The  prognosis  depends  upon  the  impairment  of  the 
reparative  power  of  the  peritoneum.  The  after-care  of  those 
cases  in  which  operative  procedures  were  of  no  avail  is  conducted 
along  symptomatic  lines.  In  those  cases  in  which  inoperable 
malignant  disease  is  present  it  is  better  not  to  take  away  from 
such  patients  the  last  ray  of  hope,  and  thus  make  the  few  remain- 
ing months  of  their  lives  gloomy  with  impending  death.  As  a 
rule,  such  patients  are  only  too  willing  to  be  deceived.  One 
should  always  protect  oneself,  however,  by  fully  informing  the 
patient's  relatives  or  friends  of  the  true  condition  of  affairs.  In 
many  cases  a  temporary  cessation  of  previously  existing  symp- 
toms will  follow  an  exploratory  procedure.  This  is  accounted 
for  by  the  separation  of  adhesions  and  the  removal  of  peritoneal 
fluid.  The  separation  of  adhesions  relieves  pain  caused  by  their 
dragging  or  pressure.  The  manipulation  of  the  peritoneum 
frequently  produces  sufficient  trauma  to  set  up  fresh  adhesions, 


OPERATIONS  UPON  THE  ABDOMEN  487 

through  which  new-formed  blood-vessels  act  as  an  adjunct  to 
the  portal  circulation,  and  thus  tend  to  prevent  a  reaccumulation 
of  the  peritoneal  fluid.  The  general  condition  of  patients  the 
victims  of  metastatic  peritoneal  cancer  with  ascites  is  much 
improved,  especially  the  breathing,  as  the  removal  of  the  fluid 
allows  of  freer  action  of  the  diaphragm. 

Tuberculous  Peritonitis. — After  abdominal  section  for  tubercu- 
lous peritonitis,  even  though  nothing  more  be  done  than  the 
mere  opening  of  the  peritoneal  cavity,  it  is  quite  common  to 
have  a  cure  follow.  Should  ascites  have  been  present  before 
the  operation,  this  does  not,  as  a  rule,  recur.  The  opening  of  the 
abdomen  and  the  entrance  of  air  produces  sufficient  traumatism 
to  enlist  the  services  of  a  large  army  of  leucocytes.  These 
attack  the  miliary  tubercles,  with  a  resulting  formation  of  new 
connective  tissues  and  consequent  cicatricial  contraction.  It 
is  not  necessary  for  a  cure  that  the  tuberculous  foci  be  removed. 
Indeed,  in  most  cases  this  is  inadvisable  for  the  reason  that  a 
fecal  fistula  is  quite  apt  to  follow  disturbance  of  intestine 
the  seat  of  tuberculosis.  Following  simple  laparotomy  or 
laparotomy  with  the  introduction  of  oxygen  the  patients 
are  relieved  of  their  symptoms,  and  in  many  cases  are  per- 
manently cured.  The  after-treatment  differs  in  nowise  from 
that  of  ordinary  cases,  except  that  in  those  cases  in  which 
adhesions  are  separated  fecal  fistula  will  probably  follow,  and 
for  this  reason  drainage  is  provided.  Nourishing  diet  and 
plenty  of  outdoor  exercise  in  a  suitable  climate  are  to  be  insisted 
upon,  as  most  of  these  cases  have  pulmonary  involvement. 

INTRAABDOMINAL  OPERATIONS  UPON  THE  UTERUS  AND  ADNEXA. 

Drainage. — Without  drainage  the  care  is  the  same  as  for  any 
clean  laparotomy,  ■  If  drainage  has  been  used  the  drain  emerges 
through  a  vaginal  incision  (see  posterior  colpotomy). 

Abdominal  Hysterectomy. — Injury  to  the  bladder  or  ureter  or 
more  rarely,  the  rectum  may  occur  (see  complications  of  vaginal 
hysterectomy).  Concealed  hemorrhage  is  a  rare  complication. 
Retention  of  urine  is  common.  Cystitis  seems  to  occur  more 
frequently  than  after  any  other  operation.  Slow  wound  healing 
and  wound  infection  may  be  expected  in  anemic  patients.     Pelvic 


488  OPERATING    ROOM    AND    THE    PATIENT 

hematoma  is  more  apt  to  occur  after  supravaginal  hysterectomy 
than  after  panhysterectomy.  It  is  rare  in  either  case.  Vaginal 
incision  is  indicated  with  expulsion  of  the  clot  and  drainage. 
Failure  to  express  the  clot  is  apt  to  result  in  infection  and 
abscess  formation. 

Extrauterine  Pregnancy. — Tubal  abortion  treated  by  posterior 
colpotomy,  removal  of  clots  and  drainage;  the  packing  is  re- 
moved in  forty-eight  hours  and  the  vaginal  wound  allowed  to 
close.     Rest  in  bed  is  maintained  for  five  to  seven  days. 

Salyingo-oo'phorectomy  for  Intraabdominal  Rupture.- — In  the 
majority  of  such  cases  the  hemorrhage  has  been  severe.  Seven 
hundred  and  fifty  cubic  centimeters  of  saline  are  given  sub- 
cutaneously  as  soon  as  the  bleeding  has  been  controlled.  The 
treatment  does  not  differ  from  laparotomy  in  general  except 
for  the  treatment  of  the  shock  and  the  longer  wound  rest  by 
reason  of  the  anemia.  This  latter  should  receive  appropriate 
treatment. 

Operations  upon  the  ovaries,  tubes,  or  ligaments  do  not  differ 
in  their  post-operative  treatment  from  laparotomy  in  general. 
Occasionally  in  young  women  the  artificial  menopause  produced 
by  double  oophorectomy  will  be  severe  enough  to  require  the  use 
of  ovarian  extract  or  warrant  ovarian  transplantation. 

Myomectomy. — Adhesion  of  the  small  intestine  to  the  uterine 
wound  may  cause  an  early  or  late  intestinal  obstruction.  This 
is  particularly  to  be  watched  for  if  the  uterine  wound  is  on  the 
posterior  surface. 

Extraperitoneal  Shortening  of  the  Round  Ligaments.  (Alex- 
ander's Operation). — The  care  of  the  wound  is  as  for  inguinal 
herniotomy.  The  uterus  is  supported  in  its  new  position  by 
packing  the  cul-de-sac.  The  patient  is  allowed  to  move  about 
in  bed  as  she  wishes.  The  vaginal  packing  is  so  placed  as  to 
allow  proper  drainage  of  the  cervical  canal.  To  accomplish  this 
two  packing  strips  are  used,  one  anterior  to  the  cervix  tightly 
applied,  the  second  below  this  loosely  applied.  The  latter  is 
removed  on  the  third  day  and  not  replaced.  The  upper  pack- 
ing is  replaced  as  it  becomes  foul.  The  support  of  the  uterus  in 
its  new  position  is  maintained  until  the  next  menstrual  period. 
The  patient  should  remain  in  bed  two  weeks  and  avoid  all  strain. 


OPERATIONS    UPON    THE    RECTUM    AND    ANUS  489 


CHAPTER  XVII. 
OPERATIONS  UPON  THE  RECTUM  AND  ANUS. 

The  chief  dangers  following  operations  upon  the  rectum  and 
anus  are  sepsis  and  hemorrhage.  Temporary  disturbances  of 
urination  are  common.  Pain  is  marked  as  a  rule.  In  addition 
incontinence  of  feces  or  cicatricial  stenosis  may  result. 

Sepsis  may  follow  any  wound  or  operation  involving  the 
rectal  mucous  membrane.  The  more  soiling  with  feces  the  more 
danger  there  will  be  of  infection.  The  entrance  of  feces  into 
the  wound  prior  to  the  formation  of  protecting  granulations 
may  cause  most  untoward  symptoms,  varying  from  those  of 
slight  inflammation  to  pyemia  and  death.  The  loose  perirectal 
connective  tissue  readily  allows  of  a  rapid  progressive  phleg- 
monous inflammation  {fecal  'phlegmon).  The  patient  complains 
of  great  lassitude,  headache,  poor  appetite,  and  there  is  a  fecal 
odor  to  the  breath.  There  is  rise  of  temperature  and  accelera- 
tion of  pulse.  Should  the  inflammation  approach  the  surface 
there  will  be  found  the  local  symptoms  of  inflammation.  Unfor- 
tunately this  is  not  always  the  case.  The  infection  may  be 
deep  in  the  retrorectal  connective  tissue  and  not  show  itself 
externally.  Thence  it  may  spread  to  the  retroperitoneal  con- 
nective tissue  and  ascend  behind  the  peritoneum,  to  form  an 
immense  retroperitoneal  abscess.  In  addition  the  infection  may 
spread  anteriorly  and  involve  the  tissues  around  the  bladder. 
In  any  event  unless  prompt  and  efficient  drainage  is  instituted 
the  patient  will  die  of  septicemia  or  peritonitis.  It  must  be 
remembered  that  a  cryptogenic  peritonitis  may  result  from  any 
wound  about  the  rectum  or  vagina. 

Treatment. — Such  a  process  can  be  avoided  by  the  strict 
preparation  of  the  patient  for  operation,  care  during  the  opera- 
tion, an  efficient  packing  of  the  wound,  and  care  in  the  after- 
treatment.  The  wound  should  be  inspected  and  a  digital 
examination  made  on  the  occurrence  of  fever  or  any  of  the 
symptoms  noted  above.     Abscess  formation  should  be  met  by 


490  OPERATING    ROOM    AXD    THE    PATIEXT 

prompt  incision  and  efficient  drainage.  Should  the  infection 
already  have  extended  to  the  retroperitoneal  tissues,  free  inci- 
sions should  be  employed  and  two  or  more  fenestrated  drainage 
tubes  be  introduced.  Smaller  abscesses  in  the  perirectal  tissue 
are  treated  as  ischio-rectal  abscess.  Thrombosis  of  the  hemor- 
rhoidal veins  occurs  through  traumatism  in  the  course  of  the 
operation.  Such  a  condition  is  not  necessarily  septic.  These 
thrombi  may  break  down,  however,  and  emboli  be  carried  to 
various  parts  of  the  body  with  resulting  pyemia.  Emboli  may 
enter  the  inferior  vena  cava  through  the  portal  vein  and  be 
carried  to  the  lungs.  If  these  are  not  of  a  septic  character  the 
symptoms  will  usually  subside  in  a  few  days.  Pulmonary 
thrombosis  may  result. 

Hemorrhage. — This  danger  is  watched  for  during  the  first 
forty-eight  hours.  Even  in  so  minor  a  procedure  as  the  removal 
of  isolated  internal  hemorrhoids  there  may  result  so  severe  a 
secondarj'-  hemorrhage  as  to  endanger  the  patient's  life.  This 
is  favored  by  the  vascularity  of  the  parts  and  the  dilatation  of 
the  hemorrhoidal  veins.  In  case  the  sphincter  is  able  to  con- 
tract the  blood  may  not  show  externally  and  herein  lies  the 
danger  that  this  complication  may  be  overlooked  until  valuable 
time  has  been  lost.  The  blood  fills  the  rectum  and  ascends  into 
the  colon.  The  symptoms  of  internal  hemorrhage  develop 
rapidly  or  slowly  according  to  the  size  of  the  bleeding  vessel. 
There  is  desire  to  go  to  stool.  When  the  bowels  do  move  a 
large  amount  of  fluid  blood  and  semi-solid  clots  are  passed. 
Treatment  consists  in  accurate  hemostasis  at  the  time  of  opera- 
tion. This  is  to  be  accomplished  by  the  ligature  and  thermo- 
cautery. Oozing  areas  are  to  be  firmly  tamponed.  If  the 
hemorrhage  is  but  slight  ice-water  enemata  will  be  sufficient;  if 
severe,  insert  a  speculum,  search  for  the  bleeding  point,  and 
ligate  it.  If  this  latter  is  impossible  the  thermocautery  may  be 
employed  and  the  entire  rectum  tightly  tamponed.  This  will 
best  be  accomplished  by  the  forcing  into  the  rectum  of  a  large 
gauze  tampon,  to  the  middle  of  which  is  fastened  a  stout  string. 
The  tampon  is  compressed  and  its  apex  anointed  with  vaselin 
to  facilitate  its  entrance.  It  is  forced  well  above  the  bleeding 
area.     The  speculum  is  then  withdrawn  and  sufficient  traction 


OPERATIONS    UPON    THE    RECTUM    AND    ANUS  491 

made  upon  the  string  to  cause  the  tampon  to  reverse  the  folded 
position  in  which  it  was  introduced,  so  that  its  inner  dry  surface 
is  brought  forcibly  in  contact  with  the  bleeding  area.  This  is  a 
painful  procedure.  The  tampon  is  allowed  to  remain  in  place 
for  from  two  to  four  days,  by  which  time  it  has  become  soaked 
with  secretion  and  comes  away  easily.  The  loss  of  blood  may 
necessitate  intravenous  infusion  and  the  usual  treatment  for 
shock.  The  "umbrella  tampon,"  a  ten-inch  square  of  gauze 
surrounding  a  thick-walled  rubber  tube  may  be  introduced  in 
place  of  the  folded  gauze  tampon.  The  interior  of  the  square 
of  gauze  is  firmly  packed  with  strips  of  gauze  until  the  rectum 
is  filled. 

Pain  varies  with  the  treatment  of  the  sphincter  ani  and  the 
extent  of  the  operation.  In  hemorrhoids  and  partial  prolapse 
the  pain  is  apt  to  be  severe  unless  the  sphincter  has  been  thor- 
oughly dilated.  The  insertion  of  a  suppository  containing  two 
grains  of  powdered  opium  will  do  much  to  allay  the  primary 
pain  of  the  operation.  This  should  be  done  directly  on  the 
completion  of  the  operation.  Operations  involving  the  sacral 
nerves  (Kraske's)  may  be  followed  by  severe  pain.  Urinary 
Disturbances. — Retention  of  urine  may  occur  after  any  opera- 
tion on  the  rectum  or  anus.  This  will  necessitate  the  use  of 
the  catheter  for  a  few  days.  As  a  rule  the  disturbance  dis- 
appears  spontaneously.     Incontinence  of  urine  is  rare. 

Wound  Treatment.— In  case  of  hemorrhoids,  as  in  operations 
for  partial  prolapse  of  the  rectum,  in  which  no  oozing  occurs  no 
dressing  other  than  an  outer  pad  is  necessary.  If  oozing  is  pres- 
ent after  any  rectal  operation  or  if  secondary  hemorrhage  is 
feared  the  rectum  is  to  be  packed.  If  provision  is  not  made  for 
the  escape  of  gas  the  patient  will  experience  great  discomfort. 
To  obviate  this  a  thick-wall  rubber  drainage  tube  surrounded 
with  a  sufficient  number  of  layers  of  plain  sterile  gauze  to  fill 
the  rectum  at  the  level  at  which  bleeding  is  expected  is  inserted. 
The  gauze  is  tied  or  sewn  to  the  tube.  Introduction  is  facilitated 
by  smearing  the  apex  of  the  "umbrella"  tampon  with  vaselin. 
Iodoform  gauze  should  never  be  used  in  the  rectum  on  account  of 
the  danger  of  absorption.  Whether  packing  is  used  or  not  a 
suppository  containing  two  grains  of  powdered  opium  is  placed 


492  OPERATING    ROOM    AND    THE    PATIENT 

in  the  rectum.  This  allays  the  pain  and  keeps  the  bowels 
from  moving  spontaneously.  The  outer  dressing  or  perineal 
pad  is  held  in  position  by  a  T-bandage.  This  is  made  to  exert 
pressure  in  case  of  external  oozing.  The  bowels  are  kept 
closed  for  four  days.  If  the  pre-operative  instructions  have 
been  followed  this  will  not  occasion  any  great  discomfort. 
Opium  is  given  by  mouth  in  rare  cases  when  a  desire  for  stool 
is  present.  The  diet  is  light,  fluid  for  the  most  part.  The 
bowels  are  moved  on  the  fifth  day  by  castor  oil  supplemented 
by  an  olive  oil  enema.  If  a  large  cavity  connects  with  the 
rectuih  as  in  resection  of  the  rectum  for  carcinoma,  or  in  large 
perirectal  abscess  cavities,  the  entrance  of  fecal  matter  into  the 
wound  before  the  formation  of  protecting  granulations  might 
result  in  severe  infection.  In  case  of  sm.all  fistulee  and  hemor- 
rhoids the  bowels  may  be  moved  on  the  third  or  fourth  day  and 
every  other  day  thereafter  until  granulation  is  well-established, 
following  which  a  daily  evacuation  of  the  bowels  is  desirable. 
The  dressing  will,  as  a  rule,  come  away  with  the  first  bowel 
movement.  In  cases  of  resection  of  the  rectum  or  in  cases  of 
large  cavities  connected  with  the  rectum  in  which  the  packing  is 
left  in  situ  for  a  longer  period  in  order  to  prevent  contamination 
of  the  wound  with  feces  the  packing  is  removed  from  the  fourth 
to  the  tenth  day.  The  rectum  is  flushed  out  with  a  high  enema 
of  soap  suds.  The  wound  cavity  is  carefully  cleansed  by  irriga- 
tion with  boro-salicylic  solution  and  with  sponge  sticks.  Follow- 
ing this  the  wound  cavity  is  tamponed.  This  second  packing 
is  left  in  place  for  four  to  six  days  and  the  process  repeated 
until  the  wound  has  passed  beyond  the  risk  of  complications 
arising  from  fecal  contamination.  In  moving  the  bowels  there 
will  necessarily  result  some  disturbance  of  wound  healing.  The 
parts  are  stretched  by  the  passage  of  fecal  masses.  This  is 
somewhat  obviated  by  softiening  the  fecal  masses  with  injections 
of  olive  oil.  Such  a  passage  is  necessarily  quite  painful.  Should 
the  sphincter  have  been  left  intact,  narcosis  may  be  necessary 
to  repack*  the  parts  effectually  in  case  of  large  cavities.  In 
resection  of  the  rectum  when  there  is  much  tension  on  the 
sutures  or  when  infection  of  the  peritoneal  cavity  is  imminent 
the  bowels  are  kept  locked  with  opium.     In  cases  in  which  there 


OPERATIONS  UPON  THE  RECTUM  AND  ANUS        493 

is  slight  danger  of  fecal  contamination  such  a  course  is  unneces- 
sary. Following  each  bowel  movement  the  parts  are  to  be 
thoroughly  cleansed  and  the  wound  irrigated  with  boro-salicylic 
solution,  dried  with  sponge  sticks  and  packed  with  plain  gauze, 
each  time  using  a  smaller  quantity  of  gauze.  To  facilitate  dress- 
ing the  patient  is  placed  on  his  side  and  the  buttocks  widely  sepa- 
rated by  the  hands  of  an  assistant.  Strong  antiseptics,  such  as 
carbolic  acid  or  bichlorid  of  mercury,  must  not  be  employed. 
An  outer  gauze  pad  held  in  place  by  a  T-bandage  completes  the 
dressing.  Aside  from  the  dressing  after  each  bowel  movement, 
the  parts  surrounding  the  wound  should  be  cleansed  at  least  once 
in  every  twenty-four  hours  following  the  first  bowel  movement. 
The  number  of  daily  dressings  will  depend  upon  the  amount  of 
discharge  and  the  number  of  movements.  Large  fistula  and 
abscess  cases  may  require  as  many  as  three  dressings  daily  for 
the  first  few  days  after  bowel  movement  has  occurred.  As 
soon  as  granulations  have  sprung  up  over  the  wound  surface 
dressing  may  be  done  at  more  extended  intervals  according  to  the 
amount  of  discharge.  Should  the  granulations  assume  an  un- 
healthy appearance,  become  covered  with  a  grayish  deposit, 
painting  with  tincture  of  iodin  will  prove  beneficial,  or  the  ni- 
trate of  silver  stick  may  be  used.  Too  profuse  granulations  are 
to  be  curetted  or  cut  away  with  scissors. 

The  comfort  of  the  patient  and  the  satisfactory  course  of  the 
wound  depends  in  a  great  measure  upon  the  cleanliness  of  the 
parts.  Prior  to  the  period  of  granulations  this  must  be  attended 
to  by  the  attendant,  but  when  the  wound  is  once  granulating 
the  patient  may  do  the  cleansing.  With  this  end  in  view  he  is 
instructed  to  wash  with  a  soft  sponge,  warm  water  and  castile 
soap  after  each  movement  and  place  clean  gauze  against  the 
parts.  At  least  once  daily,  preferably  just  before  retiring  for 
the  night,  the  patient  sits  down  for  fifteen  or  twenty  minutes  in 
a  bath  of  plain  water  as  hot  as  can  be  comfortably  borne.  This 
is  done  every  night  until  complete  healing  is  effected.  Not  only 
is  this  a  great  source  of  comfort  to  the  patient,  but  it  promotes 
healing.  A  saline  enema  once  or  twice  daily  is  indicated  if  there 
is  discharge  from  the  rectum.  Rectal  wounds,  as  a  rule,  must 
heal  by  granulation  or  a  fistula  is  likely  to  result.     To  attain 


494  OPERATING    ROOM    AND    THE    PATIENT 

this  the  wound  must  be  kept  open  and  bridging  over  at  any 
point  which  will  result  in  pocket  formation  is  to  be  prevented. 
This  is  particularly  the  case  in  cavities  which  communicate  with 
the  rectum,  fistulse,  and  those  separated  by  the  rectal  wall  above, 
perirectal  abscesses.  In  such  cases  drainage  must  be  very  free 
and  an  extension  of  the  infection  watched  for.  In  simple  fistula 
cases  in  which  the  fistulous  tract  has  been  completely  excised 
and  the  wound  sutured  with  the  view  of  obtaining  primary  union, 
the  bowels  should  be  kept  closed  as  long  as  possible  and  a  daily 
inspection  of  the  wound  made.  On  the  first  symptom  of  wound 
infection  the  sutures  should  be  removed  and  the  wound  allowed 
to  heal  by  granulation 

Extirpation  of  the  Rectum. — If  preceded  by  sigmoid  colostomy, 
or  if  the  operation  is  carried  out  by  the  abdomino-perineal  route 
(Quenu)  the  operation  loses  much  of  its  danger  and  the  after- 
course  is  simplified.  After-treatment. — There  remains  a  large 
cavity  w^hich  is  packed  firmly.  The  packing  is  allowed  to  remain 
for  from  four  to  eight  days  and  repacked  every  other  day  there- 
after until  healing  is  effected.  The  case  is  different,  however, 
if  the  extirpation  is  done  from  below  alone  or  with  temporary 
resection  of  the  sacrum,  and  then  the  cut  edges  of  the  rectum 
united  to  the  skin  or  in  the  wound.  Such  a  case  will  be  subject 
to  fecal  contamination  on  account  of  the  size  and  depth  of 
the  wound.  An  additional  danger  will  be  found  in  case  the 
sutures  should  tear  out  on  account  of  tension.  Fistulse  may 
develop. 

After-treatment. — The  suture  line  is  covered  with  plain  gauze 
and  the  parts  thoroughly  packed  following  accurate  hemostasis. 
The  bowels  are  kept  closed  by  opium  for  twelve  hours  before 
the  operation  and  for  from  six  to  ten  days  following  operation. 
Should  they  move  early  before  protecting  adhesions  have  shut 
off  the  peritoneal  cavity  there  will  be  great  danger  of  peritonitis. 
If  several  days  have  gone  by  and  the  peritoneal  cavity  is  shut 
off  there  will  still  be  some  danger  that  the  adhesions  will  be  torn 
away.  Following  the  movement  the  parts  are  carefully  examined 
and  the  condition  of  the  suture  line  noted.  If  seyaration  has 
occurred  the  resulting  raw  surfaces  or  cavities  are  carefully 
disinfected   and  packed.     The  posterior  sutures   are  the  ones 


OPERATIONS    UPON   THE    RECTUM    AND    ANUS  495 

generally  at  fault.  As  soon  as  the  sutures  have  fulfilled  their 
function,  by  the  eighth  to  the  tenth  day,  they  are  removed. 
Following  the  second  dressing  the  parts  are  dressed  every 
second  or  third  day  according  to  the  amount  of  discharge.  It 
will  be  advisable  in  every  case  to  keep  the  bowels  closed  with 
opium  until  granulation  is  well  under  way,  generally  the  eighth 
to  the  fourteenth  day.  To  facilitate  the  removal  of  the  sutures 
the  ends  should  be  left  long.  Complete  union  of  the  suture  line 
is  rare.  A  fistula  may  form  connecting  the  mucous  membrane 
of  the  attached  gut  to  the  skin  at  some  little  distance  from  the 
new  anus.  If  small  such  a  fistula  may  close  spontaneously.  If 
persistent  the  intervening  tissues  between  it  and  the  rectum 
may  be  incised  or  the  treatment  be  left  until  the  remainder  of 
the  wound  has  healed  and  the  condition  of  the  patient  has 
improved.  Partial  resection  of  the  sacrum  does  not  seem  to 
weaken  the  pelvis.  Temporary  resection  heals  by  bony  callus. 
Removal  of  the  cocctjx  has  no  bad  after-effect.  Urinary  dis- 
turbances, aside  from  that  common  to  operation  in  this  neighbor- 
hood, may  result  from  interference  with  the  sacral  nerves. 
This  disappears  spontaneously,  but  will  necessitate  the  use  of 
the  catheter  for  a  few  days.  The  higher  the  bony  resection  the 
more  liability  there  will  be  to  this  complication.  Operations 
for  the  formation  of  a  new  sphincter  ani  may  be  advisable  in  non- 
malignant  cases  if  the  cicatricial  contraction  of  the  wound  is 
not  sufficient  to  ensure  a  fair  degree  of  comfort. 

Course  of  Rectal  Wounds. — After  operations  for  hemorrhoids 
or  fistula  the  patient  may  be  allowed  out  of  bed  on  the  third  day. 
Usually  they  will  prefer  to  remain  in  bed  for  a  week.  More 
extensive  operations  require  from  ten  days  to  two  weeks  in  bed. 
An  air  cushion  or  rubber  ring  will  be  necessary  for  the  patient's 
comfort  as  soon  as  he  sits  up.  Debilitated  patients  should  be 
gotten  out  of  bed  in  a  wheel  chair  at  least  for  a  short  time  daily 
beginning  on  the  second  day. 

Stenosis. — Cicatricial  contraction  may  result  after  any  operation 
upon  the  rectum  involving  the  removal  of  considerable  tissue. 
It  may  occur  after  operation  for  hemorrhoids,  as  well  as  after 
more  extensive  procedures  for  prolapsus  or  tumor.  Following 
operations  in  which  the  sphincter  has  not  been  removed  its  occurrence 


496  OPERATING    ROOM    AXD    THE    PATIENT 

is  to  be  regretted.  Should  contraction  occur  a  course  of  anal 
dilatation  is  begun  at  once.  The  prognosis  will  be  better  in 
those  cases  which  are  recognized  early,  before  firm  cicatrization 
has  been  effected.  As  large  a  dilator  as  can  be  easily  introduced 
is  first  used.  The  size  is  increased  daily  until  full  dilatation  is 
secured.  Following  this,  dilatation  is  done  every  other  day,  then 
twice  a  week  and  finally  at  longer  and  longer  intervals.  Even 
after  an  apparent  cure  has  been  effected  these  patients  should 
report  every  few  months,  or  sooner  if  there  is  any  pain  on  defeca- 
tion, for  a  passage  of  a  dilator  to  ensure  against  contraction.  Xo 
force  is  to  be  used  in  dilating,  for  fear  of  injury  to  the  delicate 
rectal  mucous  membrane.  Intelligent  patients  may  be  furnished 
■with  a  suitable  dilator  and  instructed  in  its  use.  Such  dilators 
are  worn  during  the  night.  Recurrences  are  quite  frequent. 
Plastic  operations,  such  as  linear  incision,  multiple  incision  or 
resection  of  the  stricture,  may  be  necessary  for  a  cure. 

Following  operations  in  which  the  sphincter  ani  has  been  removed 
or  so  damaged  as  to  be  useless,  a  certain  degree  of  cicatricial 
stenosis  is  welcomed,  as  it  helps  bowel  control.  If  too  complete 
stenosis  occur,  however,  gradual  dilatation  must  be  employed. 

Incontinence  of  feces  ma}-  occur  when  the  sphincter  has  been 
sectioned  or  removed.  In  the  former  case  the  incontinence  is 
usually  temporary.  If  persistent,  excision  of  the  scar  tissue 
between  the  cut  ends  of  the  sphincter  and  suture  of  the  freshened 
muscular  surfaces  will  suffice  for  a  cure.  FolloAving  removal  of 
the  sphincter  cicatricial  contraction  may  greatly  aid  in  preventing 
incontinence,  but  in  most  cases  there  will  remain  incontinence  of 
gas  and  liquid  feces.  The  patient  may  train  himself  by  going  to 
stool  at  regular  intervals  to  control  his  movements  to  a  great 
extent.  Absorbent  pads  must  be  worn  to  prevent  soiling  the 
clothes.  Should  the  gluteal  muscles  be  involved  in  the  cicatricial 
tissue,  their  action  may  serve  to  control  the  movements  in  part. 
Plastic  operations  have  been  devised  by  which  slips  of  the  gluteal 
muscles  (Lennander)  are  stitched  around  the  rectum  to  act  in 
place  of  the  sphincter. 

Prolapse  of  the  rectum  may  recur,  though  not"  often  to  such  an 
extent  as  was  present  before  operation.  The  patient  should  be 
instructed  to  immediately  reduce  an}-  prolapse  which  occurs. 


EXTRAPERITOXEAL  OPERATIONS  UPOX  THE  KIDNEY    497 

They  should  be  warned  against  strainmg.     Urinary  disturbances 
producing  straining  should  be  corrected. 

Diet. — ^For  the  first  few  days  the  diet  is  fluid,  then  thicker 
foods  are  permitted,  but  of  a  character  to  leave  as  small  residual 
matter  as  possible  in  the  intestinal  canal.  In  extensive  opera- 
tions in  strong  patients  albumin  water  may  be  employed  for 
ten  days  as  in  Kelly's  treatment  of  complete  laceration  of  the 
perineum.  Following  the  occurrence  of  granulation  a  more 
varied  diet  may  be  allowed.  Cases  in  which  incontinence  is 
not  present  are  later  instructed  to  eat  freely  of  fruit  and  easily 
digested  food  in  order  that  the  feces,  while  formed,  will  not  pro- 
duce irritation  of  the  rectum.  Straining  is  to  be  avoided. 
Tendency  to  constipation  is  overcome  by  drugs  if  necessary. 
Usually  proper  diet  and  exercise  will  suffice.  Cases  of  incon- 
tinence are  placed  on  a  diet  which  will  result  in  more  solidly 
formed  movements;  articles  of  food  tending  to  cause  diarrhea 
are  avoided.  All  cases  are  instructed  to  pay  strict  attention 
to  cleanliness  and  to  go  to  stool  at  the  same  time- each  day. 


CHAPTER  XVIII. 


EXTRAPERITONEAL    OPERATIONS    UPON    THE    KIDNEY 
AND  URETERS. 

THE  AFTER-TREATMENT  OF  OPERATIONS  UPON  THE  KIDNEY. 

General  Rules  in  the  After-treatment  of  Operations  upon  the 
Urinary  Apparatus. — Many  operations  are  fatal  through  lack 
of  care  in  the  preparatory  treatment.  Many  cases  die  of  kidney 
insufficiency.  If  the  renal  condition  is  approximately  normal 
the  prognosis  is  good  even  after  the  most  severe  operation,  but 
if  there  is  already  an  element  of  sepsis  present  or  the  functionating 
power  of  the  kidneys  is  impaired,  uremic  septicemia  will  often 
follow  even  minor  procedures. 

General  anesthesia  markedly  raises  the  mortality  in  such  cases. 
Toxemia  through  the  use  of  antiseptics  must  be  prevented. 
Cystitis  must  receive  rigid  treatment.  The  functionating  of  the 
kidneys  must  receive  careful  attention. 

32 


498  OPERATIXG    ROOM    AND    THE    PATIENT 

In  the  after-treatment  of  operations  upon  the  kidney  and  in 
operations  upon  other  parts  of  the  urinary  apparatus,  as  in  opera- 
tions upon  other  viscera,  a  thorough  knowledge  of  the  functions 
of  the  kidney  is  indispensable.  Here,  as  in  other  operations, 
alteration  in  function  is  to  be  "watched  for  and  serious  symptoms 
combated  with  prompt  remedial  measures. 

The  Urine. — The  amount  of  urine  is  noted,  at  first  every  few 
hours,  later  daily.  The  daily  amount  is  of  especial  significance 
in  nephrectomy,  as  showing  the  capability  of  the  remaining 
kidney.  This  amount  will  vary  with  the  amount  of  secreting 
kidney  tissue  removed.  In  nephrectomy  for  long-standing 
hydronephrosis  hardly  any  change  may  be  noted,  as  the  other 
kidney  has  undergone  gradual  hypertrophy  to  compensate  for 
the  increasingly  disabled  diseased  kidney.  With  the  removal 
of  a  considerable  amount  of  functionally  active  kidney  tissue,  the 
danger  of  disturbing  the  equilibrium  of  the  remaining  kidney 
is  greatly  increased. 

Anuria  will  rarely  follow  in  cases  in  which  properly  indicated 
operative  procedures  have  been  instituted.  It  is  caused  by  reflex 
shock  to  the  renal  plexus  of  nerves  and  ma}'  occur  not  only  after 
nephrectomy,  but  after  other  operations  upon  the  urinary 
apparatus,  or  independent  of  the  character  of  the  operation,  may 
result  from  the  effects  of  the  anesthetic  on  the  kidney  structure 
itself.  It  may  last  for  hours  or  days  and  fortunately,  if  properly 
dealt  with,  only  in  rare  instances  eventuates  in  death.  The 
cause  must  be  immediately  sought. 

Following  nephrectomy  the  first  supposition  would  be  that 
there  had  been  but  one  kidney  and  that  the  extirpated  one. 
Careful  preliminary  examination  should  prevent  this  accident  or 
if  there  remain  any  doubt  of  the  existence  of  the  second  kidney, 
its  presence  should  be  demonstrated  at  the  operation  by  actual 
palpation  through  the  wound.  If  there  has  been  a  history  of 
nephrolithiasis  the  anuria  may  be  due  to  the  blockage  of  the 
ureter  of  the  unoperated  kidney  by  a  calculus.  This  can  be 
remedied  by  nephrotomy.  The  amount  of  urine  passed  in  the 
first  twenty-four  hours  depends  greatly  upon  how  much  hyper- 
trophied  the  remaining  kidney  has  become  or  how  well  fitted  it 
is  to  carry  on  the  function  of  the  extirpated  kidne3^     In  general 


EXTRAPERITONEAL  OPERATIONS  UPON  THE  KIDNEY    499 

it  may  be  stated  that  the  amount  will  be  one-half  that  usually 
passed  during  the  first  twenty-four  hours  following  operations 
other  than  those  upon  the  renal  organs.  At  the  end  of  one  week 
the  amount  of  urine  should  become  approximately  normal. 
This  does  not  mean  in  all  cases  that  the  compensating  hypertrophy 
has  become  complete,  but  only  that  the  remaining  kidney  is 
capable  of  performing  the  work  and  will  in  all  probability  become 
sufficiently  hypertrophied  to  completely  compensate  for  the 
loss  of  the  diseased  kidney.  Following  this  there  may  follow 
a  period  of  polyuria,  the  amount  gradually  becoming  normal  at 
the  end  of  several  weeks.  In  those  cases  in  which  the  remaining 
kidney  is  not  fitted  to  entirely  carry  on  the  work  unaided,  there 
will  be  found  a  compensating  hypertrophy  of  the  left  ventricle 
as  a  result  of  an  attempt  on  t-he  part  of  nature  to  relieve  the  over- 
worked kidney  by  a  greater  cardiac  activity.  If  the  remaining 
kidney  is  diseased  this  compensation  may  not  suffice  and  the 
patient  will  succumb  to  uremia.  The  time  at  which  death  will 
supervene  will  depend  upon  the  extent  of  the  lesion  in  the  remain- 
ing kidney. 

The  first  symptoms  of  anuria,  if  the  urinary  secretion  is  care- 
fully watched,  will  be  the  failure  of  any  passage  of  urine.  Cathe- 
terization will  quickly  determine  whether  this  failure  is  due  to 
simple  retention  or  to  suppression.  If  the  former,  there  will 
be  a  quantity  of  urine  in  the  bladder  sufficient  to  demonstrate 
the  functional  activity  of  the  unoperated  kidney.  If  less  than 
an  ounce  is  found  in  the  bladder,  and  a  sufficient  time  has  elapsed 
for  the  proper  secretion  of  a  greater  amount  at  that  time  following 
operation,  a  condition  of  anuria  is  to  be  suspected.  A  high 
tension  pulse  will  lead  to  investigation  of  the  functional  activity 
of  the  unoperated  kidney.  With  the  high-tension  incompressible 
pulse  is  associated  a  peculiar  brilliant  appearance  of  the  eyes  and 
a  rosy  flush  of  the  skin,  particularly  of  the  skin  of  the  face,  and 
a  degree  of  restlessness.  These  symptoms  are  of  themselves 
sufficient  to  cause  an  immediate  resort  to  remedial  measures. 
If  in  addition  to  the  above  there  be  added  violent,  continuous 
headache,  vomiting  and  marked  drowsiness,  there  can  remain 
no  doubt  of  the  diagnosis.  To  these  symptoms,  unless  inter- 
vention prove  immediately  successful,  will  be  added  partial  or 


500  OPERATIXG    ROOM    AND    THE    PATIENT 

complete   unconsciousness,    convulsions   and   the   symptoms  of 
uremic  coma. 

The  treatment  for  anuria,  to  be  effectiA'e,  must  be  undertaken 
early  in  the  course  of  the  complication.  By  far  the  greater 
number  of  nephrectomies  in  which  uremia  develops  die.  The 
best  treatment  is  preventive.  A  careful  selection  of  cases,  a 
thorough  examination  of  the  supposed  healthy  kidney,  the  selec- 
tion of  an  operative  procedure  proper  for  the  individual  case, 
care  in  the  operative  technic  to  avoid  unnecessary  injury,  and 
a  carefully  systematized  after-treatment  will  do  much  toward 
lessening  the  number  of  fatal  cases.  Yet  there  always  will 
remain  a  certain  proportion  of  cases  in  which  this  complication 
will  occur  either  from  some  one  of  the  causes  noted  above,  from 
the  anesthetic,  or  from  some  apparently  unexplainable  reason. 
Preventive  after-treatment  consists  in  efficient  pre-operative 
study  and  preparation.  In  the  first  twenty-four  hours,  in 
wrapping  the  patient  in  warm  blankets  to  produce  diaphoresis, 
the  administration  of  digitalis  in  ten-minim  doses  every  four 
hours  by  hypodermic  injection  or  by  the  stomach  if  it  will  be 
retained,  and  the  giving  of  enemata  of  one  quart  of  normal  saline 
solution  at  a  temperature  of  115°  F.  every  four  hours.  In 
addition,  hot  fluids  are  to  be  given  by  the  mouth  as  soon  as  the 
cessation  of  anesthetic  vomiting  permits.  Saline,  750  to  1000 
c.c.  is  given  by  hypodermoclysis  while  the  patient  is  still  under 
anesthesia.  In  addition  whatever  stimulation  is  necessary 
through  weak  heart  or  respiratory  action,  or  through  shock  is 
administered.  The  digitalis  should  be  stopped  at  the  end  of 
the  first  twenty-four  hours.  The  enemata  are  continued  until 
the  patient  is  taking  a  full  amount  of  fluids  by  mouth,  usually 
at  the  end  of  thirty-six  hours.  A  close  watch  is  kept  upon  the 
condition  of  the  heart,  skin  and  amount  of  urine  passed.  Should 
symptoms  of  beginning  anuria  develop  in  spite  of  every  precau- 
tion, an  intravenous  infusion  of  normal  saline  solution  at  a  tem- 
perature of  120°  F.  is  to  be  given  immediately  in  order  to  raise 
the  blood  pressure,  and  this  by  lessening  arterial  tension,  permits 
the  kidney  to  resume  its  function.  Saline  infusion  serves  the 
additional  important  purpose  of  diluting  the  toxins  in  the  blood. 
The  quantity  of  saline  solution  injected  varies  from  forty  to 


EXTRAPERITONEAL  OPERATIONS  UPON  THE  KIDNEY    501 

sixty  ounces  and  may  be  repeated  several  times,  as  often  as  the 
blood  pressure  diminishes  or  until  the  cases  become  hopeless. 
Hot  baths  may  be  employed.  Nitroglycerin  gr.  1/150  combined 
with  caffein  citrate  gr.  1  are  the  two  drugs  which  act  best  in 
this  condition.  These  doses  may  be  given  hypodermically  every 
three  hours  until  the  tension  of  the  pulse  is  relieved.  The  entire 
body  may  be  wrapped  in  cloths  wrung  out  of  hot  water,  and 
evaporization  from  them  prevented  by  covering  the  patient, 
with  the  exception  of  the  head,  with  mackintosh  or  similar 
impervious  material.  This  latter  is  done  to  stimulate  the  activ- 
ity of  the  skin.  A  tent  may  be  constructed  over  the  bed  and  the 
air  around  the  patient's  body  kept  at  a  high  temperature  by  live 
steam  from  a  croup  kettle.  The  head  should  be  kept  outside  the 
tent.  Purgatives  are  given  to  help  in  the  elimination  of  the  tox- 
ins in  the  blood.  It  is  to  be  remembered  that  the  inactivity  of 
the  kidney  may  be  due  in  part  to  the  irritating  quality  of  the 
fluid  which  is  to  be  excreted,  and  if  this  irritating  quality  is 
diluted  by  infusion  and  partially  removed  by  catharsis  and 
diaphoresis,  there  is  present  a  condition  which  is  most  favorable 
for  the  renewed  activity  of  the  kidney.  At  the  very  least  we  can 
extend  by  these  means  the  time  during  which  the  kidney  can 
recover  from  any  shock  inflicted  through  the  renal  plexus,  and 
can  adapt  itself  to  the  new  conditions.  Venesection  may  prove 
useful,  particularly  in  plethoric  patients,  by  removing  a  quantity 
of  the  toxins  with  the  withdrawn  blood.  Ten  to  sixteen  ounces 
may  be  withdrawn,  and  the  volume  of  the  blood  increased  and 
the  toxin  diluted  by  the  injection  of  double  the  quantity  of  saline 
,  solution. 

The  cheynical  and  microscopical  examination  of  the  urine  will 
show  the  condition  of  the  remaining  kidney.  The  pressence 
of  a  small  amount  of  albumin  is  not  of  signiflcance,  being  usually 
due  to  the  anesthetic  and  but  transitory.  The  use  of  strong 
antiseptics  in  the  course  of  the  operation  or  of  the  after-treatment 
will  cause  albumin  to  appear  in  the  urine.  The  withdrawal  of 
the  objectionable  drug  will  usually  be  sufficient  to  cause  the 
disappearance  of  the  albumin  in  a  few  days.  For  this  reason 
no  strong  antiseptic  should  be  used  in  a  kidney  wound  either  for 
irrigation  or  gauze  drainage.     Iodoform  and  carbolic  acid  par- 


502  OPERATIXG    ROOM    AXD    THE    PATIEXT 

ticularly  are  to  be  avoided.  The  continued  presence  of  albumin 
in  the  urine,  particularly  if  there  are  also  present  blood  and  pus, 
can  only  mean  that  the  remaining  kidney  is  diseased.  This 
condition  is  rendered  all  the  more  certain  if  a  purulent  cystitis 
or  ureteritis  of  the  operated  side  has  not  existed.  Following 
nephrotomy  the  ^presence  of  pus  or  blood  must  be  excluded  as 
coming  fron  the  operated  side.  The  first  point  to  determine 
in  such  cases  is  the  patency  of  the  ureter  of  the  operated 
kidney.  This  should  have  been  determined  during  the  operation 
by  passing  an  ureteral  catheter  downward  if  the  pelvis  of  the 
kidney  had  been  opened.  Decisive  evidence  is  furnished  by 
the  cystoscope. 

Hematuria. — Following  any  renal  operation  in  the  course  of 
which  there  is  more  or  less  handling  of  the  organ,  there  will  result 
a  temporary  hematuria.  This  will  particularly  be  the  case  when 
the  kidney  has  been  separated  from  its  fatty  capsule,  brought 
into  the  wound  and  palpated  for  stone,  and  following  exploratory 
puncture  or  incision  and  nephrolithotomy.  Following  nephror- 
rhaphy  in  which  sutures  have  been  passed  through  the  substance 
of  the  kidney,  there  will  also  be  noted  a  transitory  hematuria. 
The  amount  of  blood  will  vary  according  to  the  amount  of 
traumatism  inflicted.  If  slight,  the  presence  of  blood  may  be 
only  determined  by  the  microscope;  or  if  the  exploration  has  been 
extensive,  blood  will  appear  in  appreciable  quantities.  Such 
hemorrhage  stops  spontaneously  after  a  period  varying  from  a 
few  hours  to  four  days.     No  treatment  is  necessary. 

Renal  Wounds. — If  any  portion  of  the  kidney  has  been  left 
antiseptics  must  be  rigorously  avoided.  Kidney  tissue  is 
peculiarly  sensitive  to  the  toxic  influence  of  carbolic  acid,  iodo- 
form and  bichlorid  of  mercury.  These  drugs  will  cause  a  fatty 
degeneration  of  the  renal  tissue,  and  if  their  use  is  continued, 
result  in  parenchymatous  nephritis.  We  cannot  at  the  present 
time  avoid,  except  by  spinal  analgesia,  the  occurrence  of  tempo- 
rary albuminuria  from  the  anesthetic,  but  we  can  and  should 
prevent  the  damaging  effects  produced  by  the  action  of  deleteri- 
ous drugs,  either  directl}^  in  contact  with  remaining  kidney  tissue 
in  the  wound  or  brought  in  contact  with  the  other  kidney  through 
absorption.     Therefore  asepsis  is  to  be  preferred  to  antisepsis. 


EXTRAPERITONEAL    OPERATIONS    UPON    THE    KIDNEY         503 

Nephrorrhapy. — The  main  care  in  the.  after-treatment,  what- 
ever form  of  operation  has  been  performed,  is  the  proper  support 
of  the  kidney  by  a  suitable  dressing  until  such  time  as  sufficiently 
strong  adhesions  have  developed  to  maintain  the  kidney  in  posi- 
tion. In  order  to  support  the  kidney  several  folded  towels  are 
placed  in  front  on  the  abdominal  surface  of  the  operated  side  the 
upper  edge  of  the  pad  at  the  level  of  the  umbilicus,  and  retained 
in  place  by  adhesive  plaster  and  a  snugly  fitting  binder.  This, 
after  wound  healing  and  before  the  patient  is  up  and  about,  is 
replaced  by  a  manufactured  support  for  a  period  of  from  two  to 
six  months  following  the  operation,  such  support  being  removed 
only  for  purposes  of  cleanliness.  During  this  period  every 
strain  must  be  avoided.  The  patient  is  to  be  kept  quiet  in  bed 
for  two  to  three  weeks,  following  which  sitting  up,  out  of  bed  and 
walking  follows  as  strength  permits.  Allowing  the  patient  up 
too  soon  or  too  early  exercise  is  quite  likely  to  result  in  a  recur- 
rence of  the  trouble  or  a  stretching  of  the  scar  tissue.  In  any 
event  there  may  be  a  period  attended  with  some  discomfort, 
during  which  a  slight  stretching  of  the  scar  tissue  occurs. 

Nephrotomy. — The  difficulties  in  the  after-treatment  of  neph- 
rotomy cases  depend  largely  upon  the  diseased  condition  for 
which  the  operation  is  done.  The  chief  complications  of  the 
operation,  aside  from  those  common  to  all  renal  operations,  are 
hemorrhage  and  urinary  fistula.  The  simplest  operation  is 
exploratory  puncture.  This  operation  necessitates  the  dislocation 
of  the  kidney  from  its  fatty  capsule.  The  after-treatment  is 
somewhat  similar  to  that  of  nephrotomy.  Less  packing  is 
necessary  and  a  more  complete  closure  of  the  wound  is  permis- 
sible. The  final  packing  may  be  removed  earlier,  on  the  eighth 
day,  and  secondary  suture  used  at  that  time  to  complete  the 
closure  of  the  wound.  The  patient  may  be  allowed  out  of  bed 
on  the  fourteenth  day.  If  the  kidney  has  not  been  much  dis- 
turbed this  period  may  be  even  shorter.  A  kidney  support  should 
be  worn  for  a  period  of  six  to  eight  weeks.  If  in  addition  an 
exploratory  incision  has  been  made  or  nephrolithotomy  per- 
formed, the  stay  in  bed  will  be  slightly  lengthened.  The  pri- 
mary dressing  in  such  cases  (except  in  those  cases  which  allow  of 
immediate  suture  of  the  kidney  wound  in  which  event  the  case 


504  OPERATING    ROOM    AXD    THE    PATIEXT 

will  be  treated  as  one  of  exploratory  puncture)  will  be  so  graduated 
as  to  exert  pressure  on  the  bleeding  surface  of  the  kidney,  and 
will  be  supplemented  in  this  endeavor  by  a  supporting  pad  over 
the  kidney  and  a  binder.     This  dressing  will  not  be  removed  for 
from  forty-eight  to  seventy-two  hours,  and  then  very  carefully  to 
avoid  a  renewal  of  the  hemorrhage.     Should  hemorrhage  occur  be- 
fore this  time,  as  evidenced  by  bright  red  blood  soaking  the  dress- 
ing, the  gauze  packing  is  to  be  changed.     Should  the  loss  of  blood 
exercise  a  depressing  effect  upon  the  patient's  heart,  a  second 
operation  is  to  be  considered.     Such  an  operation  would  consist 
first  in  an  attempt  to  arrest  the  hemorrhage  by  suture,  and  this 
failing,  an  extirpation  of  a  part  or  the  whole  of  the  kidney.     An 
intravenous  infusion  should  be  given  as  soon  as  the  bleeding  is 
under  control  and  other  appropriate  remedial  measures  applied. 
The  discharge  of  urine  from  a  wound  of  this  kind  renders  frequent 
changes  of  dressing  necessary.     A  satisfactory  outer  dressing  is 
furnished  by  paper  wool  in  fiat  bags.     These  are  changed  as 
freguently  as  soiled.     The  wound  dressing  of  plain  or  zinc  oxide 
gauze  is  changed  once  or  twice  daily,  according  to  the  amount  of 
discharge.     Such  wounds  are  liable  to  fat  necrosis  and  sapro- 
phjiiic  infection.     The  discharge  of  urine  through  the  wound  will 
soon  cease  if  the  ureter  is  not  obstructed.     The  rapidity  of  its 
stoppage  also  depends  somewhat  upon  the  area  of  the  secreting 
surface  exposed.     Those  cases  in  which  the  pelvis  of  the  kidney 
alone  has  been  opened,  pyelotomy,  are  dressed  in  a  somewhat 
different  manner.     If  for  exploratory  purposes  and  the  wound  in 
the  pelvis  sutured,  a  small  strip  of  gauze  will  be  led  directly  to 
the  suture  line.     This  serves  as  a  drain  in  the  event  of  leakage. 
If  the  woimd  in  the  pelvis  has  been  left  open  to  drain  the  kidney, 
a  thick-walled  rubber  drainage  tube  of  large  caliber  surrounded 
by  gauze  is  placed  so  that  it  will  serve  as  a  conduit.     The  gauze 
packing  is  renewed  at  the  end  of  forty-eight  hours.     Thereafter 
dressing  is  done  daily  until  the  eighth  day,  when  the  wound  sur- 
face will  have  granulated  and  the  danger  of  wound  infection  be 
passed.     The  tube  may  be  removed  at  this  time  if  drainage  of 
the  pelvis  is  no  longer  desirable,  a  small  packing  taking  its  place, 
and  the  wound  allowed  to  close.     If  the  condition  of  the  pelvis  or 
ureter  does  not  permit  of  this,  the  tube  ma^'  be  left  in  situ  until 


EXTRAPERITONEAL  OPERATIONS  UPON  THE  KIDNEY    505 

the  necessity  of  draining  the  pelvis  has  passed.  In  any  event 
on  the  eighth  day  the  tube  is  to  be  removed  and  thoroughly  dis- 
infected before  being  replaced.  This  should  be  done  every  third 
day  thereafter.  Care  should  be  taken  that  undue  pressure  be  not 
exerted  by  the  tube.  The  discharge  from  the  tube  is  caught 
by  thick  pads  of  paper  wool.  This  procedure  for  pyelonephrosis 
usually  results  in  a  cessation  of  the  fever.  If,  however,  the  fever 
continues  high,  an  infection  of  the  parenchymatous  kidney 
structure  is  present,  provided  cystitis,  disease  of  the  other  kidney 
or  of  some  other  organ  can  be  excluded.  Operation  upon  the 
substance  of  the  kidney  is  then  indicated.  Nephrotomy  for 
pyelonephrosis  is  still  more  difficult  to  care  for.  Here  not  only  is 
the  pelvis  of  the  kidney  opened  and  drained,  but  the  kidney 
tissue  itself  is  freely  incised  and  all  pus  pockets  opened.  If  the 
process  has  been  long  standing  there  may  have  been  some  at- 
tempt at  isolation  of  the  abscess  cavity,  but  usually  we  have 
presented  for  wound  treatment  a  large  mass'  of  completely  or 
partially  destroyed  kidney  tissue  and  a  large  suppurating  sac, 
the  pelvis  of  the  kidney.  The  wound  is  left  open.  Thick-walled 
drainage  tubes  of  large  caliber  are  placed  in  parts  of  the  wound 
where  they  will  act  most  efficiently.  The  remainder  of  the  wound 
is  loosely  packed  with  gauze  unless  there  is  considerable  hemor- 
rhage, in  which  case  tight  tamponade  must  be  adopted  for  forty- 
eight  hours.  If  hemorrhage  is  feared,  the  dressing  is  undisturbed 
for  forty-eight  hours  and  then  carefully  renewed.  Otherwise  the 
wound  is  dressed  at  the  end  of  twenty-four  hours  and  once  or 
twice  daily  until  the  discharge  materially  lessens.  The  drainage 
tubes  are  to  be  taken  care  of  in  the  same  manner  as  when  the  pelvis 
alone  is  drained.  The  outside  pads  of  paper  wool  are  to  be 
changed  as  frequently  as  soiled.  If  the  process  is  a  tuberculous 
one  a  moderate,  irregular  fever  may  be  expected  to  continue. 
Nephrotomy  only  affords  temporary  relief  in  these  cases,  and  is  per- 
formed in  those  cases  in  which  a  more  radical  operation,  nephrec- 
tomy, would  prove  too  great  a  shock  in  an  already  emaciated 
and  feeble  individual.  These  cases  almost  invariably  require  a 
secondary  nephrectomy  before  a  final  cure  is  obtained.  In 
such  cases  the  determination  of  the  condition  of  the  second 
kidney  is  imperative.     Should  the  case  not  be  tuberculous,  a 


506  OPERATING    ROOM    AXD    THE    PATIEXT 

probable  cure  will  be  effected  by  drainage.  Wound  cleanliness 
may  be  secured  by  daily  irrigation  of  saline  solution.  Dilute 
solutions  of  potassium  permanganate  or  nitrate  of  silver  are  of 
considerable  value.  If  pus  still  finds  its  way  into  the  bladder, 
this  may  be  irrigated  daily  with  the  above  mentioned  solutions  to 
keep  the  bladder  or  other  kidney  from  becoming  infected.  If 
sluggish  granulations  develop,  they  may  be  scraped  away  with  a 
sharp  curette  and  the  wound  packed  with  plain  gauze  wrung  out 
of  a  fifty  per  cent,  aqueous  solution  of  alcohol.  Balsam  of 
Peru  is  not  to  be  used  for  this  purpose,  as  the  cinnamic  acid  it 
contains  may  prove  harmful  to  the  kidney  structure.  The 
indication  for  the  removal  of  the  tube  or  tubes  is  found  in  case 
they  no  longer  drain,  or  in  case  of  the  tube  draining  the  pelvis 
when  the  urine  escaping  through  this  becomes  normal.  Urinary 
infiltt.'ation  under  the  foregoing  treatment  cannot  occur.  After 
removal  of  the  tube  the  urinary  fistula  remaining  will  readily 
close  if  it  leads  to  parenchymatous  tissue  and  the  ureter  is  not 
stenosed  or  contracted.  If  an  opening  into  the  pelvis  of  the  kid- 
ney exists,  as  cited,  the  fistula  will  not  close  readily.  A  course 
of  wound  stimulation  and  cicatrization  is  started,  curetting, 
the  nitrate  of  silver  stick,  and  the  thermo-  or  galvanocautery 
being  employed.  If,  after  an  interval  of  several  weeks,  no  im- 
provement is  noted  the  fistulous  tract  is  dissected  out  in  its 
entirety  and  the  edges  of  the  opening  in  the  pelvis  of  the  kidney 
freshened  and  united.  A  small  gauze  drain  is  left  in  case  of 
leakage.  If  there  is  any  obstruction  whatever  in  the  course  of  the 
ureter,  such  a  procedure  will  not  be  successful.  Obstruction  may 
be  caused  by  stone,  by  narrowing,  by  cicatricial  stenosis,  by 
kinking,  or  from  disease  (tuberculosis).  Should  the  other 
kidney  be  diseased,  the  patient  must  remain  content  with  the 
urinary  fistula  except  the  obstruction  in  the  ureter  be  low  down 
near  the  bladder,  in  which  event  ureteral-vesical,  ureto-ureteral 
anastomosis  or  an  implantation  of  the  ureter  into  the  rectum 
might  be  advisable.  The  dilation  of  stricture  of  the  ureter, 
either  by  passing  flexible  sounds  from  the  pelvis  of  the  kidney  or 
by  cystoscope  through  the  bladder,  is  practicable  and  should  be 
tried.  If  the  remaining  kidney  is  healthy  and  other  means  of 
closure  fail,  the  affected  kidney  may  be  extirpated.     The  ad- 


EXTRAPERITONEAL    OPERATIONS    UPON    THE    KIDNEY  507 

visability  of  this  procedure  must  be  decided  in  individual  cases. 
A  secondary  operation  of  this  kind  offers  greater  technical 
difficulties,  on  account  of  the  adhesions,  than  a  primary  proce- 
dure. In  cases  of  hydronephrosis  alone  greater  efforts  are  to  be 
made  to  save  the  kidney.  The  hydronephrotic  sac  contracts 
with  great  rapidity.  The  most  frequent  cause  for  the  persistence 
of  the  fistula  lies  in  a  kinking  of  the  ureter  from  malposition  of 
the  kidney  pelvis.  If  so,  correction  of  the  position  of  the  kidney 
may  result  in  restoring  the  patency  of  the  ureter.  In  any  event 
the  course  of  the  ureter  should  be  explored  and  the  possibility  of 
correction  of  the  obstruction  by  resection,  dilatation,  ureto- 
ureteral  anastomosis  or  rectal  implantation  demonstrated  before 
resorting  to  nephrectomy  in  those  cases  in  which  a  fair  amount  of 
kidney  tissue  is  present.  It  is  to  be  remembered  that  the  greater 
the  amount  of  urine  flowing  through  the  fistula,  the  greater 
amount  of  parenchymatous  tissue  present,  and  hence  the  greater 
need  for  saving  such  a  kidney. 

Fat  Necrosis. — By  reason  of  the  amount  of  fat  surrounding 
the  kidney,  the  after-treatment  of  operations  upon  that  organ 
may  be  complicated  by  extensive  fat  necrosis.  If  infection 
occurs  in  addition,  the  wound  will  assume  a  greasy,  indo'lent 
aspect  and  a  saprophytic  odor  will  be  noticed.  Gauze  wrung 
out  of  a  fifty  per  cent,  aqueous  dilution  of  alcohol  is  quite 
effective  in  combating  the  infection  and  restoring  a  normal 
appearance  to  the  wound. 

Partial  Nephrectomy. — A  partial  nephrectomy,  in  which 
for  some  reason  secreting  kidney  tissue  is  left,  or  when  it  is 
found  impracticable  to  remove  the  entire  pelvis  of  the  kidney,  is 
treated  by  packing  the  wound  firmly  with  gauze  and  suturing 
the  wound  in  part,  allowing  room  for  the  emergence  of  the 
gauze  at  the  lower  angle.  This  dressing  is  changed  at  the  end 
of  forty-eight  hours  and  a  lesser  quantity  of  gauze  introduced. 
Dressings  are  done  daily  or  every  second  day,  according  to  the 
amount  of  wound  secretion.  The  wound  is  allowed  to  close  as 
rapidly  as  possible.  Secondary  suturing  may  be  employed  as 
soon  as  the  secretion  from  the  kidney  surface  has  ceased.  When 
possible  any  secreting  kidney  substance  left  or  the  lining  of  the 
pelvis  of  the  kidney  should  be  treated  with  the  thermocautery 


508  OPERATING    ROOM    AND    THE    PATIENT 

at  the  time  of  operation.  A  urinary  fistula  resulting  from  the 
leaving  behind  of  parenchymatous  tissue  is  to  be  treated  as 
previously  set  forth.  A  fistula  the  result  of  leaving  behind  some 
of  the  lining  membrane  of  the  pelvis  of  the  kidney  is  to  be 
treated  in  the  same  manner.  If,  however,  much  of  this  lining 
membrane  has  been  left  it  will  be  found  that  ordinary  means 
are  not  sufficient,  and  a  second  operation  will  be  necessary  to 
completely  destroy,  or  better,  remove  the  secreting  portions. 
Complete  nephrectomy  with  destruction  of  the  exposed  lining  of 
the  remaining  portion  of  the  ureter  with  the  thermocautery  is 
treated  by  almost  complete  closure  of  the  wound,  a  very  small 
gauze  drain  beiiig  placed  over  the  stump  of  the  ureter  to  guard 
against  retention  of  secretions  and  to  warn  of  hemorrhage  from 
the  ligated  vessels.  This  is  removed  at  the  end  of  forty-eight 
hours  and  the  wound  allowed  to  close.  If  much  serum  has 
collected  it  will  be  well  to  replace  the  gauze  drain,  with  a  small, 
one-quarter  inch  rubber  drain  until  such  secretion  lessens. 
Hemorrhage  is  rare,  but  should  be  watched  for.  Should  it 
occur,  the  wound  is  to  be  rapidly  opened  and  the  vessels  grasped 
with  the  left  hand  while  one  or  more  heavy,  long-handled 
clamps  are  applied  with  the  right  hand.  These  clamps  are 
allowed  to  remain  in  situ,  supported  by  a  gauze  packing,  for  a 
period  varying  from  three  to  four  days.  Their  removal  is  to  be 
accomplished  with  great  care.  After  nephrectomy,  as  in  all 
kidney  operations  in  which  hemorrhage  may  occur,  the  patient 
is  to  be  kept  at  absolute  rest  for  a  period  of  at  least  four  days. 
The  occurrence  of  hernia  following  lumbar  incisions  is  very  rare. 
Following  extraperitoneal  plastic  operation  upon  the  ureters, 
a  tell-tale  drain  is  left  in  place  for  forty-eight  hours.  There 
is  rarely  any  leakage  and  following  the  removal  of  the  drain  the 
tract  heals  readily. 


CHAPTER  XIX. 

OPERATIONS  UPON  THE  BLADDER. 

Puncture  of  the  Bladder. — This  operation  may  be  employed 
as  a  temporary  or  permanent  procedure  in  cases  in  which  it  is 


OPERATIONS  UPON  THE  BLADDER  509 

not  deemed  advisable  at  the  time  to  resort  to  more  extreme 
measures,  and  by  it  acute  cases  of  retention  may  be  tided  over 
for  a  few  hours  until  they  can  receive  more  radical  treatment. 
In  some  cases  emptying  the  bladder  sufficiently  relieves  the 
congestion  at  the  neck  of  the  viscus  to  allow  normal  evacuation 
later.  Chronic  cases  with  an  acute  exacerbation  may  be  also 
tided  over.  Debilitated  subjects  may  be  permanently  drained 
by  puncture,  or  at  least  until  such  time  as  their  general  condition 
sufficiently  improves  to  warrant  a  removal  of  the  cause  of  the 
obstruction. 

The  safest  and  most  direct  method  of  puncture  is  the  supra- 
pubic route.  The  parts  are  shaved  and  disinfected,  the  operator's 
hands  cleansed  and  a  large  aspirating  needle  sterilized.  If  a 
permaennt  puncture  is  to  be  made  a  large  trocar  and  cannula 
(Fig.  194)  and  a  knife  are  sterilized.     The  trocar  and  cannula 


Fig.   194. — Curved   trocar   and    cannula   for   suprapubic    puncture    of   the 
bladder.      (Fowler's  Surgery.) 

should  be  curved,  the  trocar  having  a  groove  in  its  side  to  permit 
of  the  urine  passing  as  soon  as  the  bladder  is  entered.  The 
distended  bladder  is  mapped  out  by  percussion  and  a  point  in 
the  median  line  selected  one-half  inch  above  the  symphysis. 
The  skin  is  made  tense,  and  in  case  it  is  wished  to  tide  the 
patient  over  for  a  few  hours  only,  the  aspirating  needle  is  plunged 
in  a  downward  direction  into  the  bladder,  the  urine  evacuated, 
the  needle  withdrawn,  and  the  minute  skin  opening  covered 
with  a  piece  of  sterile  adhesive  plaster.  This  procedure  may 
be  repeated  at  intervals  should  occasion  demand,  nor  need  the 
same  site  of  puncture  be  used,  but  to  one  side  or  the  other.  If 
multiple  puncture  is  to  be  performed  a  smaller  needle  should  be 
employed. 

If,  however,  permanent  drainage  is  desired,  a  small  skin  incision 
is  made  and  the  curved  trocar  and  cannula  concavity  downward 


510  OPERATING    ROOM    AND    THE    PATIENT 

to  avoid  any  possible  injury  to  the  peritoneum,  plunged  down- 
ward and  backward  through  the  tissues  and  into  the  bladder. 
Precautions. — It  must  be  remembered  that  the  fold  of  peritoneum 
reflected  on  the  superior  bladder  wall  is,  in  the  normal  condition 
of  the  organ,  below  the  level  of  the  upper  border  of  the  symphysis, 
and  that  even  in  extreme  distention  seldom  exceeds  two  inches 
above  the  symphysis.  In  some  instances  this  fold  does  not  even 
rise  ubove  the  sjmiphysis.  So  that  while  the  fundus  of  the 
bladder  may  reach  the  umbilicus,  the  portion  uncovered  by 
peritoneum  may  be  relatively  small.  This  is  mentioned  to 
emphasize  the  importance  of  directing  the  puncturing  instrument 
downward.  The  trocar  having  been  withdrawn,  the  cannula  is 
fastened  in  place  with  two  tapes  passed  around  the  body.  A 
dry  gauze  dressing  may  be  applied,  or  better,  a  small  rubber 
catheter  is  introduced  through  the  cannula  and  the  urine 
syphoned  off  by  a  Dawbarn's  apparatus.  As  soon  as  granula- 
tions have  formed,  the  apparatus  is  withdrawn  and  replaced  by 
a  Bangs  suprapubic  drain,  the  catheter  of  which  is  cleansed 
regularly  to  prevent  incrustation.  When  the  patient  is  up  and 
about  the  catheter  is  connected  with  a  rubber  urinal.  Appa- 
ratus having  in  view  the  prevention  of  the  escape  of  urine  through 
the  tube  so  that  the  flow  may  be  under  the  control  of  the 
patient  are  impractical.  When  the  case  has  been  drained  for 
a  sufficient  period,  the  catheter  is  withdrawn.  As  a  rule  the 
resulting  fistula  heals  readily,  providing  the  normal  flow  has 
been  reestablished. 

Retrocatheterization. — In  case  of  severly  lacerated  urethra  it 
sometimes  is  advisable  not  to  spend  too  much  time  and  effort 
in  an  attempt  to  enter  the  bladder  by  dissection  through  the  peri- 
neum. In  such  cases  a  small  sound  may  be  introduced  through 
a  suprapubic  cannula  and  made  to  engage  in  the  urethro-vesical 
orifice,  whence  it  is  crowded  into  the  perineum.  This  acts  as 
a  guide  and  greatly  facilitates  the  dissection  of  the  perineum. 

Infiltration  of  urine  complicates  bladder  wounds  if  drainage 
is  not  adequate.  Normal  urine  is  aseptic  but  makes  a  good 
culture  medium  so  that  if  efficient  drainage  is  not  provided  in- 
fection quickly  occurs  and  diffuse  cellulitis  results. 

Healing  in  wounds  of  the  bladder  is  retarded  by  the  flow  of 


OPERATIONS  UPON  THE  BLADDER  511 

urine  over  the  wound.  Ammoniacal  urine  causes  marked  inter- 
ference with  healthy  granulation.  The  granulations  are  sluggish 
and  grayish.  Triple  phosphates  form  incrustations  in  the  wound. 
The  treatment  is  directed  toward  securing  a  better  condition 
of  the  urine. 

Suprapubic  Cystotomy  without  Drainage.  Ideal  Suprapubic 
'  Cystotomy  with  Complete  Closure  of  the  Wound. — An  adhesive- 
plaster  Scultetus  is  applied  over  a  small  wound  dressing  of  plain 
gauze  and  the  patient  placed  in  the  elevated  head  and  trunk  posi- 
tion so  that  the  intraabdominal  pressure  will  serve  to  obliterate 
any  dead  space  in  the  space  of  Retzius.  The  patient  is  allowed 
up  in  twenty-four  hours.  A  retained  catheter  is  worn  for  seven 
days.  If,  as  in  children,  this  proves  irritating,  frequent  cathet- 
erization may  be  substituted.  Aside  from  the  usual  wound  com- 
plications pocketing  of  serum,  later  undergoing  infection  may 
occur  in  Retzius'  space.  This  requires  opening  of  the  wound 
and  drainage.  If  opening  is  delayed  extensive  cellulitis  will 
result. 

Course  of  the  Bladder  Wound  with  Tamponade  of  the  External 
Wound. — The  same  care  is  taken  to  prevent  distention  of  the 
bladder.  A  tight  binder  is  applied  and  the  patient  allowed  to 
move  about  in  bed  freely.  The  tamponade  is  removed  in  four 
days  and  the  wound  strapped.  Subsequently,  if  no  complication 
has  occurred  the  patient  is  allowed  up  and  about. 

Following  either  operation  failure  of  union  of  the  bladder 
wound  may  occur.  This  calls  for  the  introduction  of  bladder 
drainage.  Two  tubes  are  preferable  as  they  permit  of  easier 
irrigation  of  the  bladder.  Here,  unlike  temporary  drainage 
introduced  at  a  set  operation  (Gibson's  method)  it  is  difficult  to 
effect  proper  syphonage  and  frequent  change  of  urine-soaked 
dressings  is  necessary.  Following  removal  of  the  cause  of  the 
leakage  (complicating  cystitis,  infection,  infrequent  catheteriza- 
tion with  bladder  distention,  general  debility),  the  bladder 
wound  usually  heals  rapidly;  if  not,  a  secondary  operation  is 
indicated. 

Suprapubic  Cystotomy  with  Temporary  Drainage  (Gibson's 
Method). — The  after-care  of  these  cases  is  less  irksome  than 
where  separation  of  the  bladder  wound  following  complete  closure 


512  OPERATING    ROOM    AXD    THE    PATIEXT 

lias  occurred.  The  technic  of  the  operation  results  in  a  channel 
with  inverted  mucous  membrane.  This  channel  closely  grasps 
the  drainage  tube  and  leakage  is  unlikely.  Upon  withdrawal  of 
the  tube  wound  closure  promptlj'  follows.  If  permanent  supra- 
pubic drainage  is  desired  the  suprapubic  opening  is  prevented 
from  closing  by  Bangs'  suprapubic  drain  (Fig.  195),  a  catheter 
retained  in  place  by  a  specially  constructed  hard-rubber  pad  to 
which  tapes  are  attached. 


Fig.   195. — Dr.  L.   Bolton  Bangs's  suprapubic  drain.     (Fowler's  Surgery.) 

Dawbam's  Apparatus  for  Suprapubic  Drainage  of  the  Bladder 

(Fig.  196). — Properh*  arranged  this  serves  excellently  in  keep- 
ing the  parts  dry.  The  illustration  and  legend  explain  the 
application. 

The  bladder  may  be  kept  from  overflowing  and  the  patient 
kept  dry  by  a  vacuum-creating  water  nozzle  attached  through 
the  medium  of  a  large  vacuum  bottle  to  a  vacuum  tube.  The 
vacuum  tube  should  rest  inside  the  drainage  tube  and  should 
be  so  fastened  as  to  be  suspended  in  the  bladder  and  not  touch 
the  mucous  membrane.  There  should  be  plenty  of  room  along- 
side the  vacuum  tube  for  air  to  enter  the  bladder.  The  vacuum- 
creating  water  nozzle  with  various  tips  and  needles  forms  the  best 
method  of  aspirating  cavities  or  of  keeping  the  operative  field  dry. 

Lithotrity. — The  patient  is  kept  in  bed  for  a  few  davs.  The 
diet  should  be  nonirritating  and  as  much  fluid  given  as  the 
patient  can  comfortably  assimilate.  Morphin  is  given  to 
"relieve  pain  which  is  for  the  most  part  urethral  and  caused  by 
large  instruments.  Pain  is  more  severe  if  parts  of  the  stone 
have  been  overlooked  and  blood  and  epithelium  -^-ill  persist  in 
the  urine.  Small  particles  pass  or  ma}^  form  nuclei  for  more 
stones.     There  is  some  blood  and  epithelium  in  the  first  urine 


OPERATIONS  UPON  THE  BLADDER 


513 


passed,  but  no  detritus  if  the  bladder  has  been  thoroughly  washed. 
There  may  be  slight  fever  and  malaise  for  which  sodium  sal- 
icylate in  ten-grain  doses  every  four  hours  may  be  given.     If 


Fig.  196. — Dawbarn's  apparatus  for  suprapubic  drainage  of  the  bladder 
(modified).  1,  Fountain  syringe;  2,  shut-off  cock;  3,  T-connection;  4,  trap 
made  by  coiling  the  rubber  outlet  tube  on  itself  and  securing  it  with  adhesive 
plaster;  5,  catheter  passing  through  the  wall  of  the  perforated  outer  tube 
7,  which  passes  through  the  suprapubic  opening  and  rests  in  the  bladder; 
6,  Wolfe  bottle  for  collecting  the  urine;  8,  bottle  in  which  tube  7,  intended 
to  carry  off  the  urine  in  case  the  apparatus  fails  to  work  from  blocking  of  the 
catheter  or  any  other  reason,  terminates;  9,  receptacle  for  discharges  of 
water  from  apparatus.     (Fowler's  Surgery.) 


there  is  complicating  cystitis  the  fever  is  more  marked.  Cystitis 
is  prevented  and  treated  by  urotropin  gr.  viiss  combined  with 
benzoate  of  soda  gr.  x  every  four  hours.  If  the  urine  is  dimin- 
ished in  quantity  saline  is  administered  by  rectum  every  three  or 

33 


514  OPERATING    ROOM    AND    THE    PATIENT 

four  hours.  If  cystitis  persists  the  bladder  is  irrigated  (Fig.  197) 
two  or  three  times  daily  with  warm  boric  acid  solution  and  a 
half  ounce  of  10  per  cent,  argyrol  left  in  the  bladder  at  each 
irrigation.  The  bladder  should  be  thoroughly  washed  out  with 
the  evacuator  at  the  end  of  a  week  to  insure  removal  of  all 
fragments  and  a  cystoscopic  examination  made. 


Fig.  197. — Soft-rubber  two-way  catheter  for  irrigating  the  bladder. 
(Fowler's  Surgery.) 

Prostatic  Abscess. — If  the  urethra  has  not  been  opened  the 
tube  and  gauze  drainage  are  removed  in  forty-eight  or  seventy- 
two  hours  and  replaced  by  strip  drainage. 

This  is  changed  every  second  day.  Irrigation  of  the  wound  is 
unnecessary  if  incision  has  been  adequate  unless  stagnation  of 
secretion  occurs.  The  usually  accompanymg  urethritis  is  treated. 
Retention  of  urine  is  relieved  by  catheter  unless  urethritis  is 
present,  otherwise  by  suprapubic  aspiration,  using  a  small 
needle.  Several  aspirations  may  be  necessary;  usually,  however, 
one  is  sufficient  as  the  congestion  rapidly  subsides  following 
incision.  Hot  baths,  hot  enemas  and  morphin  should  be  tried 
before  aspiration  is  resorted  to. 

Perineal  Cystotomy.  After-treatment. — The  bed  ready  to 
receive  a  perineal  section  case  should  be  prepared  with  a  rubber 
sheet,  and  a  quart  bottle  should  be  swung  at  the  side  of  the  bed 
by  means  of  a  piece  of  roller  bandage,  so  fastened  as  to  allow  of 
ready  removal.  The  bottle  is  concealed  by  pinning  a  folded 
towel  around  it.  As  soon  as  the  patient  has  been  placed  in  bed 
the  perineal  tube  is  connected  with  a  tube,  thick-walled,  to 
prevent  blockage  by  kinking  or  by  the  patient's  limb  resting 
upon  it,  and  of  sufficient  lengt^i  to  reach  under  the  thigh  and 
over  the  side  of  the  bed,  there  to  enter  the  collecting  bottle. 
The  connection  should  be  of  annealed  glass.     The  tube  should  be 


OPERATIONS  UPON  THE  BLADDER  515 

of  sufficient  length  to  allow  of  the  patient's  changing  his  position 
in  bed  without  dragging  upon  the  tube.  Gauze  or  other  absorb- 
ent material  should  be  placed  against  the  perineum  to  receive 
any  urine  which  may  leak  out  alongside  of  the  perineal  tube 
and  so  prevent  wetting  the  bed.  This  gauze  is  changed  as 
frequently  as  it  becomes  saturated  not  only  for  the  sake  of 
comfort,  but  to  prevent  septic  complications  of  the  perineal 
wound.  The  same  rule  applies  to  the  bedding.  The  bottle  is 
to  be  emptied  and  cleaned  frequently  to  prevent  overflow  and 
odor.  Two  ounces  of  5  per  cent,  carbolic  solution  in  the  bottle 
will  prevent  odor.  Its  contents  are  noted,  both  as  to  quantity, 
appearance  and  odor.  A  daily  urinalysis  is  made  as  long  as  the 
tube  is  in  place  and  at  sufficiently  short  intervals  thereafter  to 
give  warning  of  the  presence  of  cystitis  or  of  its  progress  if  it  is  al- 
ready present,  or  of  complicating  renal  disease.  If  for  any  reason 
the  tube  does  not  carry  off  the  urine,  an  immediate  investigation 
is  in  order.  This  stoppage  may  occur  early,  in  the  first  twenty- 
four  hours,  or  during  the  second  twenty-four  hours,  or  after  a 
considerable  time.  The  first  step  in  investigating  the  cause  of 
this  accident  will  consist  in  thoroughly  investigating  the  patency 
of  the  tubes,  both  connecting  and  perineal. 

In  the  first  twenty-four  hours  it  may  happen  that  a  blood  clot 
from  the  bladder  has  become  lodged  in  the  tube.  It  is  to  be 
remembered  that  the  ideal  perineal  tube  projects  but  a  short 
distance,  three  quarters  of  an  inch  into  the  bladder.  The  short 
distance  is  sufficient  to  allow  for  the  pull  on  the  tube  caused  by 
swelling  of  the  perineal  woimd  and  the  tube  projects  but  a  few 
inches  beyond  the  perineum  where  it  is  connected  with  the 
larger  tube  leading  to  the  bottle.  The  advantage  of  this  is  that 
the  tube  being  short,  a  blood  clot  can  be  displaced  by  intro- 
ducing a  probe  or  thin  forceps  into  the  tube.  If  the  patency  of 
the  tube  is  assured  it  may  be  that  a  large  clot  or  a  number  of 
clots  have  collected  within  the  bladder  and  are  pressing  against 
the  opening  in  the  tube.  This  is  a  more  serious  matter.  A 
study  of  the  urine  in  the  bottle  will  aid  in  arriving  at  this  con- 
clusion. If  a  number  of  clots  and  a  quantity  of  fluid  blood  have 
passed  into  the  bottle,  this  complication  may  be  suspected. 
Irrigating  with  a  warm  solution  of  boracic  acid  or  a  minute 


516  OPERATIXG    ROOM    AXD    THE    PATIEXT 

quantity  of  equal  parts  of  peroxid  of  hydrogen  and  bicarbonate 
of  soda  followed  by  saline  irrigation  aids  in  disintegrating  the 
clots  and  alloAving  them  to  pass  or  in  bringing  them  in  reach 
of  a  pair  of  slender  forceps.  The  bladder  is  carefully  "watched 
to  preA'ent  distention.  If  all  else  fails,  the  tube  is  removed 
and  the  clots  scooped  out  with  the  finger  or  a  bkmt  spoon, 
aided  by  irrigation.  The  tube  is  then  replaced.  A  similar 
condition  attends  when  the  tube  has  become  displaced  inward, 
so  that  its  opening  is  impinged  upon  b}'  the  bladder  wall.  In 
this  case  clots  will  not  be  present  and  a  slight  withdrawal  of  the 
tube  will  reestablish  the  flow.  Or  the  tube,  through  the  restless 
tossing  of  the  patient  incident  to  his  recovery  from  the  anesthetic, 
may  ha^-e  been  displaced  outward,  the  neck  of  the  bladder 
closing  behind  it  or  on  the  o^^ening  if  a  tube  with  lateral  opening 
alone  has  been  used.  A  slight  intromission  will  cause  the  urine 
to  pass.  In  this  latter  case  no  urine  will  be  likely  to  pass  along- 
side of  the  tube,  the  bladder  will  become  distended,  possibly 
a  dribbling  will  ensue,  but  this  will  in  all  likelihood  be  through 
the  tube  and  not  alongside  of  it.  In  stone  cases  a  calculus 
which  has  been  overlooked  may  cause  the  blockage,  though 
this  would  be  a  rare  occurrence,  the  treatment  for  which  would 
be  temporary  removal  of  the  tube  and  securing  of  the  calculus. 
Xot  only  must  the  tube  be  short  in  order  to  satisfactorily  attend 
to  these  complications,  but  it  must  also  be  thick  walled,  or  the 
contraction  of  the  neck  of  the  bladder  will  shut  off  the  flow. 
A  thick-walled  rectal  tube,  36  French,  with  the  opening  at  the 
end  will  be  found  most  satisfactory. 

In  the  second  tirenty-four  hours  the  danger  from  blockage 
greatly  decreases.  The  patient  has  recovered  from  the  anes- 
thetic and  is  content  to  rest  quietly.  The  danger  from  hemor- 
rhage is  less,  though  clots  may  still  occur.  The  principal  cause  of 
blockage  during  this  time  is  from  swelling  of  the  perineum,  which 
will  result  in  dragging  outward  the  tube  which  has  been  fastened 
there  by  stitches.  To  guard  against  this  the  tube,  at  the  time  of 
operation,  is  placed  three  C|uarters  of  an  inch  beyond  the  neck 
of  the  bladder  to  allow  for  this  swelling.  Accurate  hemostasis, 
as  well  as  careful  suturing  of  the  tube  at  the  time  of  operation, 
will  tend  to  prevent   excessive  swelling.     In  addition  to  slight 


OPERATIONS  UPON  THE  BLADDER  517 

perineal  swelling,  swelling  from  extravasation  must  be  watched  for 
and  dealt  with  radically.  Any  boggy  or  reddened  areas  are  to  be 
opened  up  freely  and  drained.  If  stoppage  from  this  cause  does 
occur  the  sutures  are  to  be  cut  and  the  tube  gently  pushed  along 
until  the  flow  is  reestablished,  when  the  tube  is  again  sutured 
in  place.  Displacement  may  occur  at  intervals  during  the 
course  of  the  after-treatment.  After  the  fourth  day,  however, 
granulations  have  sprung  up  around  the  tube  and  leakage  is 
not  apt  to  produce  untoward  symptoms.  In  cases  requiring 
long-continued  drainage  if  the  tube  is  not  regularly  removed 
and  cleansed  about  every  third  day,  phosphatic  deposits  may 
occur  on  the  tube  and  produce  blockage,  or  even  if  not  extensive 
enough  for  this,  these  deposits  will  keep  up  a  degree  of  cystitis 
which  would  otherwise  yield  to  treatment.  Part  of  this  deposit 
may  become  separated  from  the  tube,  remain  in  the  bladder  and 
produce  calculi. 

In  cases  in  which  oozing  is  expected  with  consequent  clot 
formation  and  in  cases  of  cystitis  continuous  bladder  irrigation 
with  saline  is  employed  beginning  on  the  operating  table  (Young) . 
This  is  accomplished  by  using  a  double-current  perineal  tube  or 
two  tubes  may  be  laid  in  the  bladder  side  by  side  the  intravesical 
ends  being  sewn  together  and  the  ends  cut  obliquely.  Using 
two  tubes  in  this  manner  simplifies  the  care  of  the  bladder.  If 
blockage  does  occur  the  irrigation  is  changed  from  one  tube  to  the 
other  until  the  obstruction  is  overcome.  If  a  clot  becomes  en- 
gaged in  the  lumen  of  one  tube  and  the  irrigation  fails  to  displace 
it,  it  can  be  removed  by  stripping  the  tube  with  the  finger  thus 
sucking  it  along  the  tube.  In  hemorrhage  cases  it  is  important 
that  the  bladder  be  entirely  freed  from  .clots  at  the  time  of  opera- 
tion and  then  the  continuous  irrigation  at  once  instituted.  A 
large  irrigating  tube  is  necessary.  At  first  the  fluid  is  allowed  to 
flow  rapidly  but  as  it  becomes  less  bloody  the  flow  is  slowed  by 
clamping  the  irrigation  tube.  After  several  hours  it  can  be 
stopped  entirely  not  to  be  renewed  unless  hemorrhage  recurs. 

While  the  patient  is  being  transferred  from  the  table  to  the  bed 
the  bladder  is  left  full  of  fluid  to  prevent  clotting  and  both 
tubes  are  clamped. 

The  diet  for  the  first  few  days  should  be  nutritious,  but  of  a 


518  OPERATING    ROOM    AND    THE    PATIENT 

character  to  leave  small  residue  in  the  bowel.  Fluids  should  be 
given  freely  to  prevent  kidney  complications,  or  if  such  already 
exist,  to  assist  in  flushing  out  the  kidneys.  It  is  to  be  borne  in 
mind  that  blockage  of  the  flow  causing  back  pressure  on  the 
kidneys  may  result  in  kidney  complications  of  a  serious  nature, 
aside  from  the  discomfort  such  an  accident  gives  the  patient. 

In  simple  uncomplicated  cases,  such  as  stricture  or  cases  in 
which  prolonged  bladder  drainage  is  not  indicated  the  urine 
being  acid  and  aseptic  the  tube  may  be  removed  on  from  the  second 
to  the  sixth  day  and  the  patient  allowed  out  of  bed.  In  stricture 
cases  the  .sooner  the  tube  is  removed,  and  the  sooner  sounds  are 
passed,  the  less  likelihood  there  is  of  urinary  fistula.  In  cases  of 
resection  of  scar  tissue  the  tube  should  not  be  removed  except 
in  emergency  before  the  second  day,  for  it  takes  that  much 
time  for  the  anterior  portion  of  the  urethra  to  become  fixed  in 
the  wound. 

Protecting  granulations  which  prevent  infection  of  the  wound 
and  consequent  cellulitis  do  not  form  until  from  the  fourth  to  the 
eighth  day.  Subsequent  to  removal  the  patient  is  instructed  to 
urinate  standing  with  the  thighs  pressed  close  together  and  a 
folded  towel  against  the  perineum.  A  full-sized  sound  is  passed 
on  the  withdrawal  of  the  tube  and  repeated  every  other  day  for  at 
least  two  weeks,  subsequently  at  more  and  more  extended  in- 
tervals according  to  the  amount  of  contraction  for  one  year 
succeeding  the  operation.  At  least  once  every  six  months  there- 
after for  some  years  the  urethra  should  be  explored  to  ascertain  if 
any  recontraction  has  occurred.  Any  such  should  at  once  be 
treated  by  graduated  sounds^  The  introduction  of  an  instrument 
into  the  urethra  may  be  followed,  even  in  aseptic  cases,  by  a  rise 
of  temperature  and  a  chill.  The  temperature  may  go  as  high  as 
104°  or  even  higher.  This  need  not  occasion  alarm.  The 
administration  of  urotropin  in  five-grain  doses  with  sodium 
benzoate  five  grains  every  four  hours  for  several  doses  preceding 
and  following  instrumentation  acts  as  a  prophylactic. 

In  cases  of  anterior  urethrotomy  in  connection  with  perineal 
section  or  when  there  has  been  much  instrumentation,  the  patient 
will  experience  great  comfort  from  an  occasional  irrigation  of 
the    anterior   urethra.     The    urethra  should  be  irrigated  with 


OPERATIONS  UPON  THE  BLADDER  519 

potassmm  permanganate  1-5000  at  a  temperature  of  100°  F, 
before  and  following  each  instrumentation.  Ignorant  patients 
who  cannot  be  made  to  understand  the  importance  of  the  passage 
of  sounds  may  expect  a  recurrence.  The  closure  of  the  perineal 
fistula  depends  largely  upon  the  systematic  passage  of  sounds  to 
keep  the  anterior  urethra  dilated.  Healing  is  usually  effected  in 
from  three  to  six  weeks. 

In  complicated  cases,  such  as  extravasation  complicated  by 
cystitis,  cases  in  which  the  urine  is  alkaline  and  septic  the  tube  is 
to  remain  in  situ  for  a  longer  period,  and  is  not  to  be  removed, 
except  for  cleansing,  until  the  cystitis  has  subsided.  It  may  be 
necessary  in  cases  of  intractable  cystitis  to  insert  a  permanent 
drain.  The  question  whether  such  a  drain  should  be  perineal  or 
suprapubic  is  not  in  our  province  to  discuss  here.  Such  patients 
do  better,  however,  if  they  are  gotten  out  of  bed  early.  Subse- 
quently the  tube  may  be  connected  with  a  urinal  worn  inside 
the  trouser  leg. 

In  mild  cases  of  cystitis  complicating  stricture,  the  tube  may 
be  removed  early  and  the  cystitis  treated  at  frequent  intervals  by 
intravesical  irrigation.  The  medication  may  consist  of  boracic 
acid  solution  or  of  a  weak  solution  of  permanganate  of  potash, 
a  half  ounce  of  10  per  cent,  argyrol  being  left  in  the  bladder. 

Care  of  the  Wound. — The  wound  is  inspected  daily.  Should 
infection  or  retention  of  secretion  occur  in  a  wound  partially 
sutured  this  will  be  evidenced  by  redness,  swelling  and  imbedding 
of  the  sutures.  The  sutures  should  be  removed,  the  wound 
edges  separated  and  a  light  packing  introduced.  As  the  con- 
nective tissue  planes  are  not  separated  by  dense  barriers,  infec- 
tion is  apt  to  spread  rapidly  unless  free  drainage  is  provided. 
Usually  final  healing  is  uneventful  if  the  anterior  urethra  is  not 
obstructed. 

Perineal  fistula  may  result  from  errors  in  technic  at  the  opera- 
tion or  in  stricture  cases  from  the  patient's  failure  to  present 
himself  for  the  passage  of  sounds.  Sluggish  fistulae  are  cauterized 
with  a  nitrate  of  silver  stick  and  sounds  passed  frequently 
enough  to  ensure  the  patency  of  the  urethra  anterior  to  the 
fistula.  Persistent  fistula  will  need  a  plastic  operation  for  its 
closure. 


520  OPERATIXG    ROOM    AND    THE    PATIENT 

Suprapubic  Prostatectomy. — The  suprapubic  drainage  tube  is 
'of  large  caliber  and  short  (seven-eighths  inch  by  five  inches, 
Freyer).  It  has  two  large  lateral  openings  and  projects  but  a 
short  distance  into  the  bladder.  It  must  not  impinge  on  the 
opposite  bladder  wall.  Dressings  are  renewed  as  often  as  wet. 
Owing  to  the  large  size  of  the  tube  clots  are  readily  removed  with 
long  dressing  forceps.  Clots  are  most  frequent  in  the  first 
twenty-four  hours  and  are  removed  at  each  dressing.  The 
bladder  is  irrigated  once  or  twice  daily  using  a  long  glass  nozzle 
through  the  tube.  Free  outflow  of  the  irrigation  fluid  alongside 
the  nozzle  must  be  provided  to  avoid  distention  of  the  bladder. 
The  tube  is  removed  in  three  or  four  days  and  irrigation  continued 
daily  through  the  wound,  guarding  against  undue  bladder  dis- 
tention which  might  interfere  with  contraction  of  the  vesical 
prostatic  wound.  After  the  ninth  day  the  irrigations  are  done 
through  the  urethra  and  more  distention  of  the  bladder  pro- 
duced. Irrigations  are  discontinued  when  natural  urination  is 
established.  Occasionally  secondary  hemorrhage  occurs;  if  clots 
collect  in  the  bladder  the  suprapubic  tube  should  be  replaced  for 
a  few  days  and  irrigation  done  through  it. 

Perineal  Prostatectomy  (Young). — Continuous  irrigation  with 
two  tubes  (see  perineal  section)  is  employed  for  the  purpose  of 
preventing  interference  with  the  drainage  by  clots. 

Care  of  the  Wound. — The  packing  is  removed  eighteen  to 
twenty-four  hours  after  operation.  This  usually  causes  some 
hemorrhage;  to  prevent  disturbance  of  drainage  by  clot  formation 
the  continuous  irrigation  is  again  started  before  removing  the 
packing  and  continued,  usually  several  hours  after,  until  the 
flow  is  clear.  The  tubes  are  removed  several  hours  later. 
Neither  the  packing  nor  the  tubes  are  reintroduced.  For  the 
first  few  days  the  urine  escapes  through  the  perineal  wound 
necessitating  change  of  dressing  sufficiently  often  to  keep  the 
patient  comfortable.  Infection  is  prevented  by  gently  irrigating 
the  wound  several  times  daily  with  boric  acid  solution.  Infec- 
tion rarelj^  occurs  even  when  the  urine  is  foul.  Urine  soon  begins 
to  pass  through  the  natural  channel  and  by  the  end  of  three  weeks, 
often  sooner,  the  perineal  fistula  is  healed.  If  healing  is  delayed 
through    unhealthy    granulation    the   wound   is    curetted   or   a 


OPERATIONS  UPON  THE  BLADDER 


521 


thorough  application  of  the  nitrate  of  silver  stick  used  twice 
weekly. 

General  Treatment. — That  the  tissues  receive  fluid  is  all  impor- 
tant. Saline  is  administered  by  hypodermoclysis  750  to  1000  c.c. 
while  under  anesthesia.  Murphy  proctoclysis  is  given  and  con- 
tinued while  the  patient  is  in  bed.  Fluid,  especially  water,  is 
forced  by  mouth;  two  quarts  of  water  by  mouth  at  least  should 
be  insisted  upon  daily. 


Fig.  198. — Clietwood's  compression  bandage  for  epididymitis  in  the  sub- 
siding stage.  The  diseased  organ  is  isolated  with  its  scrotal  coverings  ^nd 
enveloped  with  a  piece  of  thin  rubber  dam,  fitted  to  the  parts  by  stretching. 
This  is  held  in  place  by  strips  of  adhesive  plaster.      (Fowler's  Surgery.) 


The  position  of  the  patient  is  changed  frequently  to  avoid 
hypostatic  'pneumonia.  He  is  propped  up  in  bed  after  removal  of 
the  tubes  and  is  placed  in  a  wheel  chair  on  the  second  day.  As 
soon  as  his  strength  permits  he  is  encouraged  to  take  a  few  steps 
and  is  wheeled  out  of  doors. 

Diet  is  increased  rapidly.  Urotropin  is  given,  seven  and  one- 
half  grains  three  times  daily  to  control  cystitis. 


522  OPERATING    ROOM    AND    THE    PATIENT 

The  passage  of  sounds  is  unnecessary  unless  there  has  been 
considerable  traumatism  to  the  urethra.  A  final  examination  of 
the  bladder  is  made  to  determine  its  condition  and  the  presence 
of  residual  urine. 

Post-operative  hemorrhage  rarely  occurs.  It  is  controlled  by 
repacking  the  wound. 

Epididymitis  (Fig.  198)  is  rather  frequent  and  suppurative 
epididymitis  may  occur. 

Stricture  is  very  rare. 

Incontinence  of  urine  disappears  rapidly. 

Perineal  fistula  is  rare  and  must  be  treated  by  subsequent 
plastic  operation.     Occasionally  a  pin-point  fistula  persists  which 
occasions  so  litt'le  inconvenience  that  no  operative  procedure  is 
advisable. 

Recto-urethral  fistula  rarely  occurs.  This  seems  to  be  obviated 
by  approximating  the  levator  ani  muscle  at  the  operation 
(Young). 

Sexual  power  is  lost  in  a  few  cases,  and  delayed  sometimes  as 
long  as  a  year  in  many  others. 

Natural  urination  is  restored  in  almost  all  cases.  If  obstruc- 
tion persists  it  means  that  the  operation  was  incomplete. 


CHAPTER  XX. 
OPERATIONS  UPON  THE  MALE  GENITALS. 

Meatotomy. — No  dressing  is  required  other  than  cotton  or 
gauze  to  protect  the  clothing  while  bleeding  persists.  A  full- 
sized  sound  is  passed  every  other  day  to  prevent  recontraction 
until  bleeding  no  longer  follows  its  passage.  Irritation  from  the 
urine  is  prevented  by  alkaline  diuretics. 

Circumcision. — The  main  object  of  the  after-treatment  is  to 
keep  the  line  of  incision  back  of  the  corona  otherwise  the  healing 
process  contracts  rapidly  and  subsequent  retraction  becomes 
impossible.  This  is  best  accomplished  at  the  time  of  operation 
by  the  primary  dressing.  After  the  catgut  sutures  have  been 
tied  the  ends  are  left  long.  A  srnall  roll  of  iodoform  gauze  is 
placed  around  the  penis  on  the  suture  line  and  the  long  ends  of 


OPERATIONS    UPON    THE    MALE    GENITALS  523 

the  sutures  tied  together  over  the  gauze.  HeaHng  is  complete 
in  seven  days  at  which  time  the  sutures  being  absorbed  the  dress- 
ing is  readily  removed.  Confinement  to  bed  is  unnecessary 
after  recovery  from  anesthesia.  Upon  getting  about  the  penis  is 
protected  from  friction  by  enveloping  it  in  cotton  held  in  place 
by  a  diaper  in  children  or  a  jock  strap  in  adults.  Adults  are 
given  full  doses  of  bromids  for  the  first  few  days  to  prevent  pain- 
ful erections. 

Co7nplications. — Hemorrhage  is  rare.  Oozing  is  controlled  by 
a  pressure  bandage  without  disturbing  the  dressing.  More 
pronounced  hemorrhage  is  controlled  by  ligature.  Should  a 
hematoma  form,  sufficient  sutures  are  removed  to  allow  of 
expression  of  the  clot  and  ligature  of  the  bleeding  point.  The 
wound  is  then  resutured.  Edema  occasionally  occurs  and  is 
most  marked  in  the  neighborhood  of  the  frenum.  It  usually 
subsides  spontaneously  but  if  persistent  or  marked  is  treated  by 
multiple  punctures  with  a  fine  needle  and  gentle  massage  to 
express  the  fluid.  Infection  is  very  rare.  Done  in  an  uncleanly 
manner  the  operation  has  been  followed  by  gangrenous  cellulitis 
of  the  penis,  scrotum  and  thigh  and  death  has  resulted  from 
septicemia. 

Operations  for  Paraphimosis. — If  edema  persists  employ 
multiple  punctures  with  a  fine  needle  and  gently  massage  to 
express  the  fluid. 

Suture  of  the  Perineal  Urethra. — The  retained  catheter  is  kept 
in  place  for  seven  to  ten  days.  Wound  treatment  differs  whether 
complete  wound  closure  has  been  done  or  the  urethra  alone 
sutured  and  the  rest  of  the  wound  left  open.  In  the  former  event 
the  wound  is  subject  to  the  usual  wound  complications;  in  the 
latter,  healing  by  granulation  occurs.  Subsequent  to  removal 
of  the  catheter  stricture  is  guarded  against  by  the  careful  use  of 
sounds. 

Closure  of  urethral  fistula  is  treated  on  similar  lines. 

Excision  of  Stricture  of  the  Urethra. — A  retained  catheter  is 
used  for  ten  to  fourteen  days  by  which  time  healing  has  occurred. 
The  careful  passage  of  sounds  is  then  instituted  to  ensure  against 
contraction  at  the  site  of  suture. 

Amputation  of  the  Penis. — If  the  galvano cautery   method  has 


524  OPERATING    ROOM    AND    THE    PATIENT 

been  used  the  cauterized  surfaces  are  protected  by  gauze  kept 
moist  with  saline  or  a  very  mild  antiseptic.  Sloughs  should  not 
be  forcibly  detached  but  should  be  removed  as  they  become  loose. 
The  retained  catheter  requires  the  usual  care. 

If  the  amputation  has  been  done  hy  knife  the  primary  dressing 
consists  in  a  moist  iodoform  bandage  of  the  stump  held  in  place 
by  attaching  it  to  a  double  T-bandage.  The  retained  catheter 
is  held  in  place  by  tapes.     The  dressing  is  changed  as  soiled. 

Following  either  method  the  urethral  orifice  may  tend  to 
contract.     This  is  remedied  by  the  occasional  passage  of  sounds. 

Extirpation  of  the  Penis. — The  retained  catheter,  if  used, 
serves  to  keep  the  dressing  dry.  It  is  attached  to  a  bottle  as  in 
perineal  section.  The  dressing  is  the  usual  aseptic  wound 
dressing.  The  meatus  does  not,  as  a  rule,  show  any  tendency  to 
contract;  if  it  does,  the  passage  of  sounds  corrects  it.  After 
healing  is  effected,  soiling  of  the  clothing  through  inability  to 
properly  direct  the  urinary  stream  is  avoided  by  pressing  the 
larger  end  of  a  small  funnel  against  the  perineum.  A  short 
rubber  tube  at  the  small  end  of  the  funnel  directs  the  stream. 

Epispadias.  Hypospadias. — The  complications  are  such  as 
may  be  present  in  all  wounds  plus  the  danger  of  flap  necrosis 
and  shrinkage  due  to  inefficient  blood  supply  and  the  difficulty 
of  perfectly  gauging  the  size  of  the  required  flap.  The  bladder 
is  drained  by  a  retained  catheter  for  seven  to  ten  days  when  the 
newly  formed  canal,  if  ever,  is  in  condition  to  allow  of  with- 
drawal of  the  retained  catheter.  Subsequently  the  bladder  is 
emptied  by  catheter  at  sufficient  intervals,  every  six  or  eight 
hours,  to  prevent  distention  in  cases  of  epispadias  and  in  other 
cases  if  small  granulating  defects  exist.  It  is  frequently  neces- 
sary to  perform  additional  operations  for  the  cure  of  small 
defects.  After  union  is  complete  further  dilatation  with  grad- 
uated sounds  is  employed  to  prevent  contraction. 

Complications  of  operations  involving  the  scrotum  are  those 
of  wounds  made  in  loose  connective  tissue.  Hematoma  is 
due  to  error  in  operative  technic.  If  slight,  pressure  and 
rest  will  cause  absorption;  if  extensive,  the  wound  must  be 
opened  and  the  clot  expressed.  In  the  latter  event  it  is  better 
to  insert  a  drain  for  a  few  days.     Cellulitis  is  rare.     Its  occur- 


OPERATIOXS    UPON    THE    MALE    GENITALS  525 

rence  is  followed  by  rapid  extension  in  the  loose  cellular  tissue 
and  calls  for  immediate  incisions,  drainage  and  the  application 
of  abundant  absorbent  dressing  changed  frequently  and  kept 
moist  with  an  evaporating  mildly  antiseptic  solution.  Retention 
of  urine  occasionally  occurs. 

Varicocele.  Open  Operation. — The  scrotum  is  supported  by  a 
snug-fitting  suspensory.  Two.  or  three  days'  rest  in  bed  are 
sufficient.  The  complications  are  such  as  any  clean  wound  is 
susceptible  to  with  the  additional  danger  of  slipping  of  the 
upper  ligature  through  retraction  of  the  cord.  This  is  prevented 
by  care  at  the  operation  in  sewing  the  cut  ends  of  the  cord 
together.  Unfortunately  if  it  does  occur  the  upper  portion  may 
retract  high  up  in  the  inguinal  canal  and  make  its  securing  by 
ligature  involve  a  dissection  as  for  hernia. 

Atrophy  of  the  testicle  may  occur  with  or  without  known 
injury  to  the  vas  at  the  operation. 

Injury  to  the  vas  in  the  course  of  the  operation  may  result  in 
gangrene  of  the  testicle.  It  is  better  to  castrate  at  once  on  the 
appearance  of  this  complication  rather  than  to  subject  the 
patient  to  the  dangers  of  long-continued  suppuration  by  removing 
t-he  sloughing  tissues  as  they  disintegrate. 

Undescended  testicle  offers  the  same  complications  as  hernia 
plus  the  complications  which  may  follow  operations  involving, 
the  scrotum,  testicle  and  cord.  //  Hahji's  operation  has  been 
employed  the  exposed  portion  of  the  testicle  is  painted  with 
Wolfler's  solution  to  protect  it  against  infection.  On  the 
seventh  day  the  testicle  sutures  are  removed,  the  testicle  returned 
to  the  scrotum  and  one  or  two  interrupted  sutures  employed  to 
partially  close  the  scrotal  wound.  The  operation  has  no  effect, 
except  through  error  in  technic,  upon  the  functionating  power 
of  the  testicle. 

Hydrocele.  Tapping  a  Hydrocele. — The  proposed  site  of 
tapping,  which  should  always  be  in  front,  is  first  anesthetized  by 
a  hypodermic  injection  of  a  4  per  cent,  solution  of  cocain  or  by 
freezing  with  chlorid  of  ethyl.  The  needle  of  a  hypodermic 
syringe  is  first  introduced  until  the  fluid  flows.  This  needle 
is  left  in  situ.  The  hydrocele  is  now  grasped  behind  with  the 
left   hand^   the   fluid   contents  forced  forward   and  the  trocar 


526 


OPERATING  ROOM  AND  THE  PATIENT 


introduced  by  a  slight  boring  motion.  The  point  of  the  index- 
finger  of  the  hand  grasping  the  instrument  is  placed  firmly 
against  the  trocar  about  an  inch  from  its  point,  in  order  to 
prevent  the  latter  from  entering  the  cavity  too  suddenly  and 
injuring  the  testicle  (Fig.  199).  As  a  further  precaution  against 
the  latter  accident  the  point  should  be  depressed  as  it  enters 
the  cavity.  An  ordinary  aspirator  may  be  employed.  When 
the  sac  is  emptied,  20  to  100  minims,  according  to  the  size 
of  the  hydrocele,  of  a  95  per  cent,  solution  of  pure  liquid 
carbolic    acid    is   introduced    through    the   previously  inserted 


Fig.  199. — Tapping  a  hydrocele.      TFoAvler's  Surgery.) 

hypodermic  needle.  The  cannula  is  now  withdrawn  and  the 
sac  manipulated  so  as  to  distribute  the  carbolic  acid  evenly 
about  the  interior.  Some  swelling  follows,  which  subsides  in 
the  course  of  a  week  or  ten  days,  during  which  a  suspensory 
bandage,  padded  with  cotton,  is  worn.  It  is  not  usually  neces- 
sary to  confine  the  patient  to  the  house  after  twenty-four  hours. 
Should  excessive  reaction  occur  Avith  eA'idences  of  tension  from 
the  presence  of  fluid  in  the  tunica  vaginalis,  secondary  aspiration 
should  be  performed  and  the  patient  kept  in-  bed  for  a  few  days 
with  the  scrotum  supported.  A  permanent  cure  is  usually 
effected  at  one  sitting.  Exceptionally,  a  recurrence  may  take 
place,  when  a  larger  amount  of  carbolic  acid  should  be  used. 


OPERATIONS    UPON    THE    FEMALE    GENITALIA  527 

Injection  methods  except  in  young  children  and  in  recent  hydro- 
cele are  unsafe  and  unreliable.  The  scrotum  is  supported.  The 
injected  agent,  usually  carbolic,  may  produce  severe  inflamma- 
tory changes.  This  is  controlled  by  rest  in  bed,  elevation  of  the 
scrotum  and  ice  locally. 

Operation  Securing  Cure  through  Granulation  (Volkmann). — 
The  primary  packing  is  removed  after  four  days,  the  cavity 
being  lightly  repacked.  Repacking  is  done  every  second  day 
thereafter  until  healing  is  effected.  A  suspensory  is  worn.  One 
or  two  days  are  sufficient  for  the  patient  to  be  in  bed. 

Operation  without  Packing  (Longuet). — The  wound  is  sealed 
and  treated  as  any  clean  wound  in  the  skin.  A  suspensory  is 
worn. 

Castration. — At  the  operation  the  vas  is  not  ligated  but  is 
removed  by  torsion  at  a  higher  level  than  the  cord,  consequently 
the  artery  of  the  sac  may  later  bleed  and  cause  a  hematoma  deep 
in  the  pelvis.  This  rarely  occurs.  Hemorrhage  may  follow 
slipping  of  the  ligature  as  in  varicocele  operations.  Hernia  is 
prevented  by  suturing  the  walls  of  the  canal.  Seven  or  eight  days' 
rest  in  bed  are  necessary  if  a  partial  hernia  operation  has  been 
added  to  the  castration,  otherwise  two  or  three  days  are  sufficient. 
The  wound  is  subject  to  the  usual  complications,  involving  the 
scrotum.  If  extensive  or  for  infective  processes,  drainage  is 
employed. 


CHAPTER  XXI. 

OPERATIONS  UPON  THE  FEMALE  GENITALIA. 

Curettage. — The  after-treatment  will  differ  according  to  the 
condition  of  the  uterus  curetted.  In  case  of  simple  endometritis 
the  patient  is  allowed  to  move  about  in  bed  freely  for  the  first 
day,  sit  up  in  bed  on  the  second  day,  out  of  bed  on  the  third  day 
and  walk  about  on  the  fourth  day.  A  uterine  packing  is  now 
rarely  employed  save  in  case  of  profuse  oozing.  If  oozing  is 
expected,  ergotol  should  be  administered,  the  first  dose  thirty 
minims  by  hypodermic  while  the  case  is  still  under  the  anesthetic, 
succeeding  doses,  one  teaspoonful  in  amount,  three  in  number 


528  OPERATING    ROOM    AND    THE    PATIEXT 

at  two-hour  intervals  upon  recovery  from  anesthesia.  If  A'omit- 
ing  is  persistent  half  the  latter  amount  may  be  given  by  hypo- 
dermic in  place  of  bj'  mouth  at  the  same  intervals.  Hypodermics 
of  ergotol  are  to  be  made  as  seldom  as  possible  as  they  are  painful 
and  occasionally  produce  intense  local  irritation.  A  warm,  not 
hot,  bichlorid  of  mercury  (1-10,000)  vaginal  douche  of  two 
quarts  is  given  on  the  third  day. and  on  each  succeeding  day, 
alternate  day  or  each  third  day  according  to  the  amount  of  the 
vaginal  discharge.  Subsequently  in  cases  of  stenosis  of  the  cer- 
vix dilatation  by  bougie  is  done  at  sufficiently  frec[uent  intervals 
to  ensure  proper  patency  of  the  os  or  a  Dudley  operation  may  be 
indicated.  The  dilatation  by  bougie  should  be  clone  shortly 
aft-er  menstruation.  If  done  shortly  before  menstruation  it 
might  interfere  ^\'ith  a  possible  impregnation  and  so  defeat  the 
object  for  which  dilatation  of  the  stenosed  os  is  frequently  done. 
In  severe  cases  of  stenosis,  obstructive  dysmenorrhea,  dilatation 
must  be  done  more  frecjuently  and  the  marital  relations  arranged 
accordingly. 

Following  curettage  for  incomplete  abortion  the  treatment  is  as 
above  outlined  except  that  uterine  inertia  is  more  apt  to  occur 
and  may  necessitate  a  more  prolonged  use  of  the  ergotol  but  at 
more  extended  intervals.  Unless  every  particle  of  the  fetus  and 
placenta  has  been  accounted  for  such  cases  should  be  observed 
over  a  period  of  several  months  to  see  if  metrorrhagia  or  too  fre- 
quent menstruation  develops,  in  which  event  a  second  curettage 
will  reveal  an  overlooked  portion  of  placenta.  If  the  abortion 
is  after  the  third  month  of  fetal  development  the  sta}'  in  bed 
should  be  prolonged  to  five  or  seven  days  but  the  patient  ma}" 
move  about  in  bed  or  sit  up  in  bed  if  she  wishes.  T\"hen  curettage 
is  done  for  subinvolution  a  longer  rest  in  bed,  from  ten  to  fourteen 
days,  is  preferable. 

Following  curettage  for  septic  endometritis  usually  accompanied 
with  more  or  less  metritis  and  parametritis  (the  curettement  in 
these  cases  being  usually  a  gentle  removal  of  detritus  with  a  dull 
irrigating  curette)  the  treatment  consists  in  elevating  the  head 
of  the  bed  in  an  attempt  to  establish  better  drainage  of  the  uterus, 
to  localize  the  pelvic  infection  and  to  favor  expulsion  of  gases; 
in  warm  intrauterine  douches  of  bichlorid  of  mercurv  1-10,000  one 


OPERATIONS    UPON    THE    FEMALE    GENITALIA  529 

quart  or  more  if  the  return  flow  is  cloudy,  using  a  dilating  in- 
trauterine douche  nozzle  which  will  allow  a  free  return  of  the 
irrigating  fluid,  at  intervals  of  four  hours  if  the  temperature  con- 
tinues high  and  at  longer  intervals  as  the  progress  of  the  infection 
is  subdued.  The  rectum  should  be  emptied  daily  by  a  copious 
enema  of  soap  suds  and  hot  water.  Small  doses  of  magnesia  sul- 
phate should  be  given  to  ensure  a  fluid  condition  of  the  intestinal 
contents,  usually  one  dram  of  the  saturated  solution  every  two  or 
three  hours  will  suffice.  The  diet  should  be  highly  nutritious, 
small  in  amount  and  of  a  character  to  leave  the  smallest  residue 
In  the  intestinal  canal.  Should  the  case  in  spite  of  the  above  go 
on  to  pelvic  cellulitis  and  peritonitis,  hot  vaginal  douches,  bichlo- 
rid  of  mercury,  1-10,000,  four  quarts,  should  be  given  every  four 
hours,  the  bowels  should  be  kept  at  absolute  rest,  a  continuous 
trickle  of  hot  saline  solution  into  the  rectum  should  be  instituted 
to  cause  reverse  absorption  in  the  hemorrhoidal  veins  and  lym- 
phatics and  so  lessen  the  danger  of  general  sepsis,  the  extreme 
elevation  of  the  head  and  trunk  should  be  employed  to  aid  in  lo- 
calization of  the  infection,  nothing  should  be  allowed  by  mouth 
in  order  to  prevent  peristalsis,  and  the  patient  should  be  kept 
quiet.  If  at  the  end  of  forty-eight  hours  improvement  occurs 
brandy  water  in  ounce  doses  may  be  allowed  by  mouth  every 
hour  or  two  and  feeding  by  rectum  at  six-hour  intervals  may  be 
instituted.  Vaginal  examination  will  reveal  either  a  subsidence 
of  the  inflammation  or  a  localization  in  the  form  of  beginning 
abscess  formation.  If  the  latter,  the  process  is  allowed  to 
continue  until  the  formation  is  sufficiently  evident  to  allow  of 
easy  incision.  This  may  be  done  by  simple  puncture  of  the 
abscess  with  slightly-curved  sharp-pointed  scissors  under  local 
anesthesia.  Should,  instead  of  localization  in  the  pelvis,  evidence 
of  general  infection  develop,  posterior  colpotomy  with  gauze 
packing  of  the  pelvis  should  be  performed  and  the  general  treat- 
ment of  sepsis  instituted  i.e.,  strychnia  sulphate,  whiskey,  nour- 
ishing diet,  injection  of  the  appropriate  vaccine  and  repeated 
saline  enemata. 

Complications  of  Curettage. — The  operation  may  be  complicated 
by  a  tear  of  the  cervix  by  the  dilator.  This  is  rare  and  usually 
easily  repaired  unless  the  tear  involves  the  broad  ligament  when 

34 


530  OPERATING    ROOM    AND    THE    PATIENT 

troublesome  bleeding  is  apt  to  result  and  a  hysterectomy  may  be 
necessary  to  control  it.  If  hysterectomy  is  not  necessary  the 
after-treatment  is  as  for  trachelorrhaphy.  The  uterus  may 
by  'perforated  by  the  sound  or  curette.  This  need  occasion  no 
alarm  unless  septic  conditions  are  present;  the  uterus  should  be 
gentlj^  curetted,  the  cavity  of  the  uterus  packed  and  the  patient 
placed  in  the  elevated  head  and  trunk  position  until  danger  of 
peritoneal  infection  is  past.  No  intrauterine  irrigation  should 
be  employed  on  account  of  the  danger  of  forcing  the  fluid  into 
the  peritoneal  cavity.  The  packing  should  be  left  in  situ  for 
forty-eight  to  seventy-two  hours  and  then  removed  gently  so  as 
to  avoid  both  bleeding  and  the  dragging  down  into  the  uterus  of 
the  omentum  which  in  these  cases  glues  itself  into  the  puncture. 
Trachelorrhaphy. — The  patient  should  be  kept  in  bed  for  a 
week  to  ten  days  but  allowed  to  move  freely  about  in  bed  and  sit 
up  in  bed  if  no  perineal  operation  has  accompanied  the  trachelor- 
rhaphy. The  only  reason  for  keeping  the  patient  in  bed  at  all  is 
the  dragging  down  the  uterus  has  received  during  the  operation, 
though  there  is  nothing  to  prove  that  cases  would  not  do  equally 
as  well  up  and  about  after  the  third  day.  The  care  of  the  diet  and 
bowels  is  as  usual  for  patients  confined  to  bed.  The  care  of  the 
cervix  differs  according  as  absorable  or  non-absorbable  suture 
material  has  been  used.  If  absorbable,  chromic  catgut,  douches 
should  not  be  given  until  the  tenth  day  when  the  vagina  may  be 
gently  cleansed  with  a  quart  of  warm  two  per  cent,  bone  acid 
solution  using  a  large  glass  nozzle  with  the  openings  on  the  sides 
and  none  on  the  tip.  Douches  given  early  in  cases  in  which 
chromic  catgut  is  the  suture  material  employed  are  apt  to  result 
in  premature  softening  and  loosening  of  the  sutures  and  severe 
secondary  hemorrhage  even  though  great  care  is  observed.  If 
nonabsorbable  sutures  of  silver  wire  are  used,  douches  may  be 
given  earlier  without  danger  of  loosening  of  the  sutures  but  in  no 
event  should  douches  be  given  if  possible  before  the  tenth 
day.  By  the  tenth  day  if  the  proper  technic  has  been  carried 
out  by  the  operator,  i.e.,  the  removal  of  all  scar  tissue,  the  leaving 
of  a  broad  enough  strip  of  mucous  membrane  to  allow  for  a 
sufficient  canal,  complete  hemostasis,  accurate  apposition  of  raw 
surfaces  and  proper,  not  too  tight,  tension  of  the  sutures,  cervix 


OPERATIONS    UPON    THE    FEMALE    GENITALIA  531 

wounds  are  usually  healed  though  not  firmly.  It  is  not  perhaps 
the  place  in  a  book  on  after-treatment,  to  call  attention  to  opera- 
tive technic  but  most  of  the  bad  results  of  trachelorrhaphy  are 
directly  due  to  transgressions  of  the  ordinary  rules  of  wound 
treatment.  On  the  twelfth  to  fourteenth  day  if  nonabsorbable 
sutures  have  been  used,  the  patient  is  placed  in  the  Sims'  position, 
a  Sims'  speculum  introduced  and  the  sutures  removed.  In 
removing  sutures  it  is  best  to  grasp  the  uppermost  suture  on 
each  side  at  the  knot,  or  twist  if  wire  has  been  used,  cutting  the 
suture  to  one  or  the  other  side  of  the  grasping  forceps  and  with- 
drawing each  suture  as  cut.  The  cervix  should  not  be  pulled 
down  with  a  t-enaculum  as  this  tends  to  disturb  the  recently 
healed  wound.  If  a  perineorrhaphy  has  also  been  performed  it  is 
best  to  leave  nonabsorbable  sutures  until  the  eighteenth  day 
in  order  not  to  subject  the  perineum  to  strain.  Absorbable 
sutures  do  not,  as  a  rule,  require  removal;  they  come  away  of 
themselves  when  the  deeper  part  of  the  suture  has  been  absorbed. 
Sometimes,  however,  an  occasional  suture  is  not  absorbed.  If 
so  it  may  be  removed  at  the  final  examination  of  the  patient  at 
which  time  a  sound  should  be  passed  to  demonstrate  the  patency 
of  the  cervical  canal.  While  removing  the  sutures  it  will  be  noted 
that  even  those  not  too  tightly  tied  at  the  operation  have  be- 
come slightly  imbedded  in  the  tissues  and  the  outline  of  the 
cervix  will  be  accordingly  slightly  nodular.  This  irregularity 
evens  out  in  the  course  of  time.  If  the  time  for  the  operation  has 
been  badly  chosen  or  if  an  irregular  menstrual  period  occurs  at 
the  time  set  for  removal  of  the  sutures,  the  removal  should  be  de- 
layed until  after  the  period.  Small  cleansing  douches  should  be 
ordered  if  there  is  any  vaginal  discharge.  Frequently  the 
sutures  will  come  away  with  the  douche. 

Amputation  of  the  Cervix.  Dudley  Operation  for  Cervical 
Stenosis. — The  after-treatment  is  as  for  trachelorrhaphy. 

Complication  of  Operation  upon  the  Cervix. — Hemorrhage 
occasionally  occurs.  It  may  follow  injudicious  douching.  If 
not  controlled  by  removal  of  the  clots  and  vaginal  tamponade  it 
must  be  controlled  by  suture. 

Anterior  Colporrhaphy. — If  absorbable  sut«ure  material  has 
been  used  a  vaginal  douche  should  not  be  given  until  the  tenth 


532  OPEEATIXG    ROOM    AXD    THE    PATIENT 

day.  Distention  of  the  bladder  with  consequent  pressure  on  the 
suture  line  is  prevented  by  catheterization  every  six  or  eight 
hours.  If  the  anterior  colporrhaphy  is  done  in  connection  with 
perineorrhaphy  the  rules  applying  to  the  after-treatment  of  that 
operation  apply.  If  done  independently,  however,  the  bowels 
may  be  moved  on  the  second  day,  the  patient  allowed  up  in  bed 
on  the  fourth  day,  and  out  of  bed  as  soon  thereafter  as  she  desires. 

Urethral  Fistula. — A  retained  catheter  is  kept  in  place  for 
seven  days.     Cystitis  is  treated  along  the  usual  lines. 

Vesico -vaginal  Fistula. — The  retained  catheter  is  kept  in  the 
bladder  for  seven  days.  A  careful  watch  is  kept  and  if  it  becomes 
displaced  accidently  it  is  at  once  replaced.  Should  cystitis  be 
present  or  supervene  the  bladder  is  washed  out  two  or  three 
times  daily  through  the  retained  catheter  with  boric  acid  solution, 
allowing  not  more  than  two  ounces  of  the  solution  to  be  in  the 
bladder  at  one  time.  If  hemorrhage  into  the  bladder  occurs 
from  the  cut  mucous  membrane  the  bladder  is  irrigated  more 
frequently  until  all  danger  of  clotting  is  passed.  Should  more 
severe  hemorrhage  occur  so  that  there  is  danger  of  the  bladder 
becoming  filled  up  with  blood  clots  continuous  irrigation  is  in- 
stituted through  a  double-current  catheter.  This  is  continued 
until  the  flow  is  clear  and  renewed  upon  the  reappearance  of 
bleeding.  Continuous  irrigation  in  this  manner  requires  very 
careful  watching  as  the  outflow  tube  may  become  blocked  and 
the  bladder  overdistended.  During  the  irrigation  it  must  be 
continually  watched.  It  will  rarely  happen  that  such  a  measure 
will  need  to  be  instituted.  Distention  of  the  bladder  either  by 
urine  or  blood  clot  through  obstruction  of  the  retained  catheter 
will  cause  too  severe  a  strain  upon  the  recently  sutured  wound 
and  its  consequent  probable  separation.  The  bowels  are  kept 
closed  for  three  days  to  avoid  strain  upon  the  sutures.  If, 
owing  to  error  in  operative  technic  a  ureter  has  been  included  in 
the  suturing  there  will  be  a  diminution  of  the  amount  of  urine 
and  pain  in  the  kidney  region  of  the  affected  side;  if  both  ureters 
have  been  included  in  the  sutures  there  will  follow  anuria  and  pain 
in  both  kidney  regions.  This  error  can  only  be  remedied  by 
immediate  removal  of  the  sutures.  No  vaginal  douches  are 
given.     After  the  removal  of  the  retained  catheter,  catheteriza- 


OPERATIONS    UPON    THE    FEMALE    GENITALIA  533 

tion  is  employed  every  six  hours  to  prevent  distention  of  the 
bladder  unless  the  patient  urinates  freely.  The  patient  is  kept 
in  bed  while  the  self-retained  catheter  is  in  place  but  is  allowed 
to  move  about  freely. 

Recto-vaginal  Fistula. — The  after-treatment  is  as  for  com- 
plete laceration  of  the  perineum. 

Perineorrhaphy. — Perineorrhaphy  for  recent  complete  lacera- 
tion is  treated  by  absolute  rest  in  bed  for  fourteen  days.  The 
patient  should  not  attempt  to  move  herself  about;  she  should  be 
moved  from  side  to  side  and  on  one  side  and  the  other  by  the 
nurse.  The  catheter  should  be  used  for  ten  days  at  eight-hour 
intervals.  The  external  parts  are  irrigated  with  warm  boric 
acid  solution  following  catheterization  and  subsequently  dried 
and  a  dry  soft  absorbent  gauze  pad  applied.  If  the  patient  is 
restless  it  is  better  to  restrain  the  limbs  for  ten  days  by  a  loosely 
applied  figure-of-eight  bandage  of  the  knees,  at  least  during 
the  sleeping  hours  and  while  recovering  from  anesthesia.  The 
preparation  of  the  patient  should  have  been  such  as  to  leave 
the  intestinal  tract  empty.  An  opium  suppository  is  given 
by  rectum  to  control  tenesmus  and  severe  pain.  The  bowels  are 
not  allowed  to  move  for  ten  days  nor,  for  the  same  period,  is 
anything  given  by  the  mouth  except  brandy-water,  plain  water 
as  much  as  desired,  albumin  water  (Kelly),  two  ounces  every 
two  hours  and  orange  juice  in  small  amounts  much  diluted. 
On  the  tenth  day  the  bowels  are  moved  with  repeated  small 
doses,  one  or  two  teaspoonfuls,  of  the  saturated  solution  of 
sulphate  of  magnesia  every  one  or  two  hours  to  produce  an 
osmosis  of  the  intestinal  canal,  followed  by  an  eight-ounce  oil 
enema  given  low  when  there  is  a  tendency  for  the  bowels  to 
move.  The  latter  renders  the  movement  much  easier.  At  the 
time  of  t'he  movement  the  perineum  should  be  supported  by 
the  nurse.  Following  the  movement  the  external  parts  are 
irrigated  and  thoroughly  dried.  If  there  is  much  pain  an  opium 
suppository  may  be  administered.  Subsequently  the  bowels  are 
moved  daily  by  enemata,  the  diet  rapidly  increased  and  on  the 
fourteenth  day  the  patient  allowed  to  sit  up  in  bed",  on  the 
sixteenth  day  out  of  bed  in  a  chair  and  on  the  eighteenth  day 
to  take  a  few  steps.     The  wound  should  be  inspected  frequently 


534  OPERATING    ROOM    AXD    THE    PATIEXT 

and  treated  on  general  wound  principles.  Sutures  should  be 
removed  on  the  tenth  to  fourteenth  day.  These  wounds  are  in 
edematous  tissues  and  require  the  most  absolute  rest  for  a  proper 
final  result. 

In  old  complete  laceration,  i.e.,  laceration  without  edema  of  the 
tissues,  the  treatment  need  not  be  so  rigid  though  the  same 
general  principles  obtain.  Catheterization  ma}'  be  dispensed 
with,  the  patient  need  not  keep  so  quiet.  The  diet  should, 
however,  be  extremely  light  and  of  such  a  nature  as  to  leave  the 
smallest  possible  residue  in  the  intestinal  tract,  preferably  plain 
water,  orange  juice,  brandy-water  and  albumin  water  for  the 
first  five  to  seven  days,  then  fluids  of  all  kinds,  moving  the  bowels 
with  the  precautions  outlined  on  the  tenth  day.  Otherwise 
the  treatment  is  for  recent  complete  laceration. 

Following  operation  for  incomplete  laceration,  whether  old  or 
recent  the  principal  treatment  is  frecpent  cleansing  and  drying  of 
the  operated  parts.  The  diet  should  be  light,  the  bowels  moved 
on  the  third  daj^  with  castor  oil  to  produce  one  movement,  rather 
than  with  salts  which  produces  several  watery  movements. 
When  desire  for  stool  is  felt  olive  oil  should  be  injected  into  the 
rectum.  Subsequently  the  bowels  are  nioved  daily  by  small 
high  enemata.  Enemata  are  given  high  to  avoicl  distention  of 
the  rectum  and  too  severe  strain  on  the  levator  ani  muscles. 
In  the  after-treatment  of  all  operative  work  in  this  region  in  the 
female  due  thought  must  be  given  to  the  physiology  of  defeca- 
tion. The  patient  may  move  about  freeh'  and  be  propped  up 
with  pillows  on  the  twelfth  day.  The  sutures  are  removed  on  the 
twelfth  day.  The  patient  is  allowed  to  sit  out  of  bed  on  the 
fourteenth  day  and  walk  about  on  the  fifteenth  daj'. 

Following  all  perineorrhaphies  the  wound  must  be  kept  dry  and 
clean  in  accordance  with  the  principles  of  wound  treatment.  If 
the  sutures  draw  the  parts  somewhat  inward  or,  as  in  fat  patients, 
the  skin  surfaces  lie  in  contact,  maceration  and  irritation  are 
prevented  by  placing  a  narrow  strip  of  dry  gauze  between  the 
surfaces.     This  strip  is  changed  frequently. 

Interference  with  Wound  Healing. — Occasionally  and  usually 
due  to  the  poor  general  condition  of  the  patient,  the  wound  will 
be  slow  in  healing  and  may  even  separate  to  some  extent.     Such 


OPERATIONS    UPON    THE    FEMALE    GENITALIA  535 

wounds  are  encouraged  to  granulate  by  ordinary  wound  treat- 
ment, the  only  difference  being  that  the  dressing  i-s  done  more 
frequently  than  in  the  case  of  wounds  elsewhere,  i.e.,  several 
times  daily.  Occasionally  as  a  result  of  improper  preparation 
the  rectum  will  become  packed  with  feces.  In  such  an  event 
the  patient  will  complain  of  pain  with  tenesmus  which  may  be 
accompanied  with  leaking  of  liquid  feces  but  an  inability  to 
move  the  bowels  properly.  A  digital  examination  of  the  rec- 
tum will  reveal  the  condition  and  the  hardened  feces  should  be 
removed  with  the  finger  or  with  a  spoon. 

Rarely  a  hematoma  forms  in  the  perineal  tissues.  Once 
started  it  usually  extends  rapidly  and  calls  for  opening  of  part 
of  the  wound  and  expression  of  the  clot.  The  cavity  is  packed 
and  a  secondary  suturing  done  at  the  end  of  forty-eight  hours. 

Should  the  perineum  prove  too  high  a  second  slight  plastic 
operation  may  be  necessary.  This  should  be  left  for  several 
months.  The  patient  is  instructed  to  avoid  all  strain  for  at  least 
two  months. 

Care  in  Operating. — No  amount  of  care  in  the  after-treatment 
will  take  the  place  of  proper  operative  measures  for  the  cure  of 
vaginal  and  perineal  lacerations.  The  final  result  will  be  bad 
if  the  proper  operative  procedure  has  not  been  well  carried  out  or 
if  the  patient  was  not  a  fit  subject  for  operation.  Anemia,  next 
to  improper  technic,  is  the  chief  reason  for  failure. 

Excision  of  Urethral  Caruncle. — If  the  excision  has  been  made 
by  knife  and  subsequent  suturing  no  wound  treatment  is  neces- 
sary. Sutures  which  have  not  been  absorbed  are  removed  on  the 
fifth  to  the  seventh  day.  If  the  excision  has  been  by  cautery 
vaselin  is  frequently  applied  to  the  resulting  raw  surface.  Rest 
in  bed  is  unnecessary.  Coincident  cystitis  requires  appropriate 
treatment.  In  properly  selected  cases  the  results  are  immedi- 
ately good. 

Posterior  Colpotomy. — If  gauze  is  employed  this  is  removed 
on  the  second  to  the  fourth  day  to  prevent  damming  back  of  the 
wound  secretions,  and  a  second  packing  of  less  bulk  introduced. 
This  is  best  done  with  the  patient  in  the  dorsal  position,  retrac- 
tion being  used  to  give  a  clear  view  of  the  procedure.  Care 
should  be  taken  not  to  break  up   adhesions.     The  vagina  is 


536  OPERATING    ROOM    AND    THE    PATIENT 

loosely  packed.  Forty-eight  hours  later  the  second  packing  is 
removed,  using  retraction  as  before,  and  the  wound  gently 
irrigated  with  boro-salicylic  solution.  The  retraction  permits 
of  a  free  return  of  the  irrigating  fluid  and  obviates  the 
possibility  of  breaking  up  the  newly  formed  adhesions  which 
shut  the  wound  off  from  the  peritoneal  cavity.  These  changings 
of  dressing  and  irrigation  are  repeated  daily  until  the  tenth  day 
when  one  or  more  daily  douches  may  be  instituted  in  their  place. 
Every  second  or  third  day,  however,  the  parts  are  to  be  examined 
ocularly  and  treated  on  general  wound  principles,  peroxid  of 
hydrogen  being  used  if  the  distharge  is  pussy,  stimulation  by 
means  of  balsam-of-Peru  gauze,  and  gentle  curettage  of  exuberant 
granulations.  If  tube  drainage  has  been  combined  with  gauze 
drainage,  either  alongside  the  tube  or  throughout  its  lumen,  the 
gauze  is  removed  as  outlined  above,  but  the  tube  is  allowed  to 
remain  in  situ,  being  withdrawn  a  short  distance  each  day,  on 
the  second  and  fourth  day.  On  the  fifth  da}^  it  is  removed  en- 
tirely, and  the  resulting  cavity  loosely  filled  with  gauze.  If  the 
colpotomy  wound  proper  contracts  too  rapidly,  a  short  tube  may 
be  introduced  to  keep  it  open  until  the  main  wound  cavity  has 
contracted  in  due  proportion.  After  the  second  day  the  bowels 
are  to  be  moved  by  enema  or  saline  laxative.  These  patients 
are  allowed  to  move  about  in  bed  after  the  fourth  day.  They 
should  be  allowed  to  sit  up  in  bed  early  as  the  downward  intra- 
abdominal pressure  serves  to  cause  an  earlier  obliteration  of  the 
dead  space  in  the  pelvis  and  facilitates  drainage.  If  secondary 
hemorrhage  is  feared  the  dorsal  posture  should  be  maintained  for 
seventy-two  hours. 

Septic  cases  do  much  better  if  thej^  are  allowed  up  in  bed.  If 
too  weak  to  sit  up  in  bed  the  elevated  head  and  trunk  position 
should  be  employed.  They  are  allowed  out  of  bed  any  time 
after  the  fourth  to  the  sixth  day  and  walk  about  as  soon  as  their 
strength  permits,  usually  on  the  sixth  to  the  eighth  day. 

Complications. — Fecal  fistula  occasionally  follows  posterior 
vaginal  section.  It  is  due  in  most  cases  to  an  extension  of  the 
infectiA^e  process  involving  the  wall  of  the  adjacent  intestine 
and  occurs  four  or  five  days  after  the  operation.  Occasionally 
the  rectum  itself  is  injured  at  the  operation.     The  occurrence 


OPERATIONS    UPON    THE    FEMALE    GENITALIA  537 

of  this  complication  calls  for  the  removal  of  all  packing  and  fre- 
quent irrigation.  The  lower  bowel  is  kept  empty  by  irrigating 
with  a  Kemp's  tube.  These  fistulse  usually  heal  spontaneously. 
A  tube  introduced  into  the  rectum  during  the  vaginal  irrigation 
allows  of  the  ready  escape  of  any  fluid  which  enters  the  intestine. 
For  the  same  purpose  while  the  rectum  is  being  irrigated  a 
vaginal  speculum  is  introduced. 

Vaginal  Hysterectomy.  Clamp  Method.— The  clamps,  the 
handles  tied  with  silk  to  preclude  accidental  loosening,  are 
removed  at  the  end  of  seventy-two  hours.  The  blades  are 
first  separated  very  gently  and  are  held  separated  for  ten  minutes 
before  removal  so  that  if  bleeding  occurs  they  can  be  reclamped. 
The  packing  is  renewed  twenty-four  hours  later  and  daily 
thereafter.  Douching  is  employed  only  if  there  is  foul  discharge. 
Care  must  be  exercised  in  douching  that  no  fluid  be  forced  into 
the  peritoneal  cavity.  The  patient  sits  up  in  bed  on  the  second 
day  following  removal  of  the  clamps  and  thereafter  is  treated 
as  if  operated  by  the  suture  method.  It  is  better  to  keep  the 
patient  on  a  light  diet  and  not  move  the  bowels  until  the  third 
day. 

Suture  Method. — The  drainage  strip  is  removed  at  the  end 
of  forty-eight  hours  and  the  vaginal  vault  tamponed  daily  there- 
after until  the  wound  is  healed.  Douches  are  given,  when 
indicated  only,  with  great  care.  The  patient  sits  up  in  bed  on 
the  fourth  day,  is  lifted  out  of  bed  to  a  chair  on  the  fifth  or 
sixth  day,  takes  a  few  steps  on  the  following  day  and  thereafter 
gradually  increases  the  amount  of  daily  exercise.  The  bowels 
are  moved  on  the  third  day  by  laxative.  To  avoid  straining  an 
olive-oil  enema  is  given  when  the  bowels  show  a  tendency  to  move. 
Method  by  Clamps  and  Midtiple  Iodoform  Packing  Strips  in 
Septic  Conditions.— The  patient  is  immediately  placed  in  the 
elevated  head  and  trunk  position.  As  soon  as  the  anesthetic 
sickness  has  passed  the  bed  is  leveled  and  the  patient  is  sat 
up  in  bed.  When  the  patient  desires  to  sleep  the  elevated  head 
and  trunk  position  is  again  used.  Perineal  pads  are  changed 
as  soiled.  The  clamps,  preferably  Pryor's,  are  removed  with 
care  at  the  end  of  forty-eight  hours.  The  iodoform  pack  is 
not  removed  until  the  fifth  or  sixth  day  unless  increased  tem- 


538  OPERATIXG    ROOM    AXD    THE    PATIEXT 

perature  develops  in  ^^■llicll  case  it  is  removed  on  the  increasing 
of  the  fever.  Only  those  strips  or  parts  of  strips  which  come 
away  easily  are  removed;  those  which  "stick"  are  cut  level 
with  the  vulva  and  left  for  twelve  hours  longer  or  until  they  are 
sufficiently  loose  to  be  removed  without  danger  of  causing 
bleeding.  Each  day  a  portion  of  the  packing  is  removed  until 
the  ninth  day  when  the  remainder  is  removed  and  the  wound 
repacked  lightly.  On  the  succeeding  day  the  patient  sits  out 
of  bed  and  on  the  day  following  takes  a  few  steps.  The  vaginal 
wound  rapidly  contracts  so  that  in  a  few  days  after  the  final 
removal  of  the  original  packing  all  dressing  may  be  omitted 
and  a  daily  douche  given.  The  bowels  are  moved  daily,  at 
first  by  enema,  later  by  laxatiA'es. 

Complications  of  Vaginal  Hysterectomy. — These  are  due  for 
the  most  part  to  errors  in  operative  technic  which  are  in  large 
measure  unavoidable.  Injury  to  the  ureter  occurs  occasionally, 
dueinmostinstancestoshavingthe  ureter  too  closely  in  operating 
for  malignant  disease.  Rarely  is  the  ureter  cut  or  ligated.  Most 
frequently  the  injury  is  to  the  blood  supply  which  results  in 
necrosis  of  a  part  of  the  uret-er  days  or  in  some  instances  weeks 
after  the  operation.  The  existence  of  such  an  injury  is  sho'v^Ti 
by  part,  or  the  whole  in  case  both  ureters  are  involved,  of  the 
urine  passing  per  vaginam.  The  exact  location  of  the  lesion  can 
only  be  determined  by  a  cystoscopic  examination.  At  first  the 
wound  is  kept  clean  and  stimulated  daily  for  several  weeks  until 
all  hope  of  the  fistula  closing  spontaneously  has  passed.  A  second 
cystoscopic  examination  is  then  made  to  verify  the  first  and 
the  appropriate  plastic  procedure  instituted. 

If  the  ureter  has  been  cut  the  symptoms  will  be  immediate. 
If  the  ureter  has  been  ligated  there  will  be  pain  in  the  kidney 
region  of  the  affected  side  and  a  lessened  quantity  of  urine. 
Cystoscopy  is  employed  to  determine  the  exact  condition. 
Treatment  consists  in  reopening  the  woimd,  and  reapplying 
the  ligatures  with  the  ureteral  catheter  in  position  for  manipula- 
tion, a  tedious  and  difficult  procedure. 

The  prevention  of  injury  to  the  ureter  consists  in  the  pre- 
liminary introduction  of  catheters  into  the  ureters  to  serve  as 
a  suide  to  their  location. 


OPERA.TIONS    UPON    THE    FEMALE    GENITALIA  539 

Injury  to  the  bladder  or  rectwn  is  rare.  Daily  careful  cleansing 
of  the  raw  surfaces  usually  suffices  to  cause  spontaneous  closure 
of  the  defect.  If  not,  a  second  plastic  operation  must  be 
undertaken. 

Hemorrhage  is  rare. 

Infection  unless  already  present  is  almost  unknown.  It  is 
treated  by  the  elevated  head  and  trunk  position  and  by  the 
usual  methods  of  combating  infection. 

Intestinal  obstruction  occasionally  occurs  through  adhesion  of 
a  small  intestinal  coil  to  the  raw  surfaces  in  the  pelvis.  Before 
proceeding  to  laparotomy  for  its  treatment  the  pelvic  pack  is 
removed  and  an  attempt  made  to  free  any  adherent  gut  by  the 
finger  introduced  through  the  vaginal  wound.  If  this  is  not 
successful  laparotomy  is  indicated. 

Intercourse  after  Plastic  Operations  upon  the  Female  Geni- 
talia.— The  time  at  which  intercourse  may  be  begun  depends 
upon  the  character  of  the  operation  and  the  general  condition 
of  the  patient.  So  far  as  the  mechanical  part  of  the  operation 
is  concerned,  two  months  or  until  after  the  third  menstrual 
epoch  is  sufficiently  long.  The  patient  and  her  husband  should 
be  instructed  as  to  the  nature  of  the  operation  as  it  affects 
the  act  of  intercourse;  for  example,  the  change  in  the  direction 
of  the  vaginal  canal  after  high  perineorrhaphy,  or  the  shortening 
of  the  canal  after  panhysterectomy.  Following  curettage  the 
interdiction  of  intercourse  depends  upon  whether  pregnancy 
is  desired.  If  so,  intercourse  should  be  begun  just  before  the 
expected  time  of  the  next  menstruation.  In  any  case  if  the 
general  condition  of  the  patient  is  poor,  intercourse  should  be 
but  sparingly  indulged  in  until  the  general  condition  markedly 
improves.  In  gonorrheal  infection,  intercourse  is  interdicted 
until  both  husband  and  wife  are  free  from  infection. 

Obstetric  Operations.  The  Surgery  of  Pregnancy. — 1.  The 
after-care  of  an  impacted  'pregnant  uterus  which  has  been  reduced 
preferably  under  nitrous  oxid  adesthesia  consists  in  inserting  a 
large-sized  Smith  Hodge  pessary  to  be  worn  till  the  fourth  month 
and  rest  in  bed  for  a  few  days  after  the  operation.  2.  The  after- 
care of  all  abortions  and  inductions  of  labor  is  similar  to  that 
employed  in  normal  labors,  rest  in  bed  for  seven  days  and  no 


540  OPERATING    ROOM    AND    THE    PATIENT 

vaginal  treatment,  3.  The  after-care  of  all  abdominal  operations 
undertaken  during  pregnancy  is  the  same  as  when  these  opera- 
tions are  done  when  pregnancy  does  not  exist;  save  for  the 
regular  administration,  for  the  first  five  days,  of  morphin  in 
minute  doses  or  codein  hypodermically,  to  try  and  prevent 
.  abortion. 

The  Surgery  of  Labor. — 1.  The  after-care  of  the  delivery  of  the 
child  per  vagina  by  any  means  except  cutting  operations  is  similar 
to  the  management  of  normal  post-partum  cases.  Douching 
should  never  be  employed.  Packing  is  used  only  for  the  control 
of  hemorrhage  and  when  employed  the  entire  genital  tract 
is  to  be  tightly  tamponed.  2.  The  after-care  of  cases  in  which 
vaginal  extraction  is  preceded  by: 

a.  Section  of  the  pelvis,  either  symphysiotomy  or  pubiotomy, 
consists  in  holding  the  patient's  legs  in  abduction  immediately 
after  the  cutting  of  the  bones  to  prevent  undue  separation.  The 
vagina  should  be  snugly  tamponed  to  prevent  the  formation  of 
a  vaginal  hematoma.  The  patient's  pelvis  immediately  after 
the  completion  of  the  extraction  is  to  be  surrounded  by  a  band  of 
adhesive  plaster  ten  inches  wude  extending  from  below  the  tro- 
chanters to  above  the  brim  of  the  pelvis.  The  ends  of  this  band 
are  split  into  two  strips  for  a  distance  of  ten  inches  and  these  are 
applied  anteriorly  similarly  to  the  Boldt  binder.  No  further 
restriction  is  placed  on  the  patient's  movements.  The  vaginal 
packing  is  removed  at  the  end  of  twenty-four  hours.  Catheteri- 
zation is  employed  every  eight  hours  prior  to  the  removal  of  the 
packing.  The  bowels  are  moved  by  enema  on  the  third  day, 
the  patient  being  carefully  lifted  on  to  a  very  low  douche  pan 
for  this  purpose.  The  patients  are  gradually  allowed  to  sit  up 
in  bed  from  the  twelfth  to  the  sixteenth  day,  are  out  of  bed  on  the 
seventeenth  day  and  allow^ed  to  walk  on  the  twentieth  day. 

b.  Section  of  the  Perineum — Episiotomy,  or  Section  of  the  Cervix 
by  Multiple  Incisions. — The  after-treatment  of  Diihrssen's  opera- 
tion consists  in  carefully  suturing  all  wounds  with  No.  2  chromic 
catgut,  and  in  applying  the  usual  care  of  the  puerperium, 

c.  Section  of  the  Lower  Zone  of  the  Uterus — Anterior  Vaginal 
Hysterotomy — Vaginal  Cesarean  Section. — Hemorrhage  from  the 
uterus  is  controlled  by  hypodermics  of  thirty  minims  of  ergot ol 


OPERATIONS    UPON    THE    FEMALE    GENITALIA  541 

followed  by  thirty  minims  of  pituitrin.  A  small  drain  of  iodo- 
form gauze  should  be  left  along  the  suture  of  the  uterus  and 
extending  out  through  the  suture  line  of  the  vagina.  This  is 
removed  after  twenty-four  hours.  Tamponade  of  the  vagina 
for  twenty-four  hours  prevents  undue  oozing  from  the  under  sur- 
face of  the  bladder  where  it  was  separated  from  the  vagina  and 
uterus.  This  is  removed  at  the  end  of  twenty-four  hours.  The 
patient,  after  reacting,  is  placed  in  the  elevated  head  and  trunk 
position  to  aid  drainage  and  involution.  Catheterization  is 
employed  every  eight  hours  until  the  gauze  is  removed  from  the 
vagina.  All  packing  used  should  be  from  a  strip  seven  yards 
long  and  twelve  inches  wide  folded  into  a  strip  two  inches  wide. 
Great  care  is  exercised  to  close  all  small  lacerations  of  the  vagina 
or  perineum  with  chromic  catgut  to  prevent  infection.  The 
patient  is  allowed  out  of  bed  on  the  twelfth  day.  3.  The  after- 
care of  cases  in  which  the  child  is  delivered  by  the  abdominal  route. 

a.  Classical  Cesarean  Section. — The  uterus  is  kept  firmly  con- 
tracted by  the  administration  of  pituitrin  immediately  after  its 
closure  by  sutures;  in  addition  ergotol  is  given  hypodermic  ally, 
thirty  minims  repeated  every  two  hours  for  three  doses.  The  ab- 
domen is  strapped  firmly  from  the  pubes  to  one  inch  above  the 
height  of  the  incision  and  a  many  tailed  binder  is  applied.  The 
external  genitals  are  cleansed  and  a  sterile  dressing  applied  and 
changed  as  in  any  puerperal  case.  As  soon  as  reaction  has  oc- 
curred the  patient  is  placed  in  the  elevated  head  and  trunk  posi- 
tion to  aid  drainage  and  involution  of  the  uterus.  Saline,  one 
pint,  is  given  by  rectum  every  six  hours  for  forty-eight  hours, 
the  first  two  containing  one  ounce  each  of  whiskey.  Distention 
of  the  upper  abdomen,  particularly  the  stomach,  is  watched  for 
and  met  promptly  by  lavage  and  enemata.  Unless  infection  is 
suspected  the  wound  is  not  dressed  until  the  twelfth  day  when 
the  sutures  are  removed.  The  abdomen  again  is  strapped  and 
the  patient  allowed  out  of  bed  on  the  fourteenth  day. 

6.  Suprasymphyseal  Section  and  Extraperitoneal  Section  by 
Inguinal  Incision. — The  after-care  is  as  in  the  classical  Cesarean 
operation. 

c.  Celiohysterectomy  with  intrapelvic  treatment  of  stump,  is  the 
same  as  in  any  abdominal  hysterectomy. 


542  OPERATING    ROOM    AND    THE    PATIENT 

d.  Celiohysterectomy  ivith  Extraperitoneal  Treatment  of  the 
Stump. — Separate  collodion  gauze  dressing  of  the  upper  part  of 
the  abdominal  wound  prevents  its  infection.  The  clamps  across 
the  pedicle  of  the  cervix  are  kept  carefully  wrapped  in  sterile 
gauze.  The  danger  of  hemorrhage  is  much  less  where  clamps  are 
used  in  preference  to  pins.  The  surface  of  the  stump  is  kept 
well  powdered  with  10  per  cent,  iodoform  in  boric  acid  and  the 
dressings  changed  once  a  day.  In  two  weeks  the  slough  will 
permit  of  the  gentle  separation  of  the  clamps.  The  granulating 
surface  is  kept  carefully  cleansed.  Suppuration  seldom  occurs  if 
this  is  done,  and  the  usual  treatment  for  granulating  wounds 
applied.  The  patient  should  not  sit  up  until  the  wound  is  firmly 
healed.  In  other  regards  the  treatment  of  these  cases  is  as  in 
all  abdominal  wounds.  Sterile  dressings  should  be  kept  applied 
to  the  external  genitals  as  long  as  any  vaginal  discharge  is 
present. 


CHAPTER  XXII. 
OPERATIONS  ON  THE  VERTEBRAL  COLUMN. 

Laminectomy. — If  there  is  no  paralysis  the  after-treatment  is 
simple.  The  extradural  drain,  if  employed,  is  renewed  at  the 
end  of  twenty-four  to  forty-eight  hours.  Escape  of  cerebro- 
spinal fluid  is  minimized  by  pressure.  Infection  is  prevented  by 
careful  and  frequent  renewal  of  dressings  if  leakage  occurs. 
Otherwise  the  treatment  is  as  for  any  clean  wound.  As  the 
rigidity  of  the  spine  is  not  impaired  by  the  operation  no  support- 
ive dressing  is  necessary.  The  lateral  posture  prevents  undue 
pressure  on  the  wound.  If  paralyses  complicate  they  receive  ap- 
propriate treatment,  massage,  electricity,  passive  motion  of  the 
joints,  apparatus  to  prevent  deformity.  The  patient  should  be 
gotten  into  a  wheel  chair  and  out  in  the  fresh  air  and  sunshine  as 
soon  as  possible,  usually  at  t^he  end  of  seven  days  when  wound 
healing  is  fairly  strong.  Since  the  spine  does  not  need  support 
there  is  no  reason  for  keeping  these  patients  in  bed  after  super- 
ficial wound  healing  has  occurred. 

Operations  for  Fracture  or  Fracture  Dislocation. — The  patient 


OPERATIONS  ON  THE  VERTEBRAL  COLUMN         543 

is  placed  on  a  water  or  air  bed  to  prevent  bedsores.  The  utmost 
eare  must  be  used  in  handling  patients  to  prevent  further  injury 
to  the  cord.  Fractures  in  the  cervical  region  are  treated  by  an 
extension  and  immobilization  apparatus  similar  to  that  used 
in  torticollis.  After  six  weeks  the  head  and  neck  are  supported 
as  in  the  after-treatment  of  cervical  spondylitis.  In  fracture  of 
the  dorsal  and  lumbar  region  immobilization  is  secured  by  a 
plaster-of -Paris  jacket.  The  most  scrupulous  cleanliness  must  be 
observed.  Parts  exposed  to  urine  and  feces  should  be  frequently 
cleansed,  dried  and  powdered.  Pain  is  relieved  by  morphin. 
Owing  to  the  insensibility  of  the  skin  and  the  trophic  disturbances 
due  to  the  injury  these  patients  are  prone  to  develop  acute 
decubitus.  The  sacrum  is  particularly  liable  to  this;  such  a  sore 
may  be  so  extensive  as  to  involve  the  bone  and  give  rise  to  general 
septic  infection.  The  catheter  should  be  employed  early  to  avoid 
ischuria  paradoxa  (retention  of  urine  with  dribbling).  If  the 
pressure  on  the  cord  has  not  been  early  relieved  progressive 
myelitis  will  develop  later.  In  any  event  with  injury  to  the  cord 
other  than  commotion  complete  return  to  normal  is  not  possible. 
Later  ascending  myelitis  develops.  The  points  subject  to  pres- 
sure should  be  protected  by  air  cushions  and  rings  of  gauze  and 
cotton.  Later  in  the  case  electricity,  massage,  hot  and  cold 
bathing  and  passive  exercises  are  indicated.  Contractures  are 
prevented  by  these  measures  and  by  apparatus. 

Treatment  of  the  Wound. — The  extradural  drain  either  wicking 
or  soft-rubber  tube  is  removed  in  twenty-four  or  forty-eight 
hours.  The  drainage  during  the  first  twelve  hours  is  usually 
very  free  requiring  frequent  change  of  outer  dressings.  Persis- 
tent leakage  is  treated  by  pressure.  Special  care  must  be  ex- 
ercised to  prevent  infection  through  soiling  by  the  discharges 
from  the  paralyzed  bowel  and  bladder.  The  chief  post-operative 
dangers  are  shock  and  infection.  Other  complications  result 
from  the  paralyses  and  enforced  rest;  cystitis  and  kidney  infection 
and  pneumonia  are  common  causes  of  death. 

Treatment  following  the  Forcible  Corrections  of  the  Deformity 
in  Pott's  Disease. — A  plaster-of -Paris  jacket  is  applied  including 
the  pelvis,  dorsal  and  lumbar  regions  and  the  head.  A  small 
window  is  left  open  over  the  point  of  greatest  deformity.     If  an 


544  OPERATING    ROOM    AND    THE    PATIENT 

open  operation  (Calot)  has  been  done  as  when  the  spines  and 
laminae  are  fused  together  (synostosis)  the  wound  is  treated  as  for 
operations  for  fracture. 

Treves'  Operation  for  Caries.^Dressings  are  changed  as  soon 
as  the  discharge  soils  the  externl  portion  of  the  dressing.  Irriga- 
tion of  the  wound  is  practised  at  each  change  of  dressing.  The 
large  rubber  drainage  tube  is  shortened  as  healing  progresses. 
Treves  uses  iodoform  gauze  for  the  packing. 

Post-operative  Treatment  of  Pott's  Disease. — Incision  is 
usually  delayed  until  the  overlying  skin  has  become  involved. 
The  external  dressings  should  be  copious  and  changed  as  fre- 
quently as  soiled.  Daily  antiseptic  irrigation  of  the  wound 
should  be  practised  with  gradual  shortening  of  the  drainage  tube. 
In  favorable  cases  the  intraabdominal  pressure  may  finally 
lead  to  obliteration  of  the  abscess  cavity. 

Spina  Bifida. — -Following  plastic  operations  the  patient  is 
kept  on  the  side  to  avoid  pressure  on  the  wound.  There  is 
usually  considerable  leakage  of  spinal  fluid  for  the  first  few  hours 
and  in  some  cases  this  continues  for  days  requiring  frequent  and 
careful  change  of  dressing.  Most  cases  surviving  radical  treat- 
ment finally  die  of  hydrocephalus  or  the  secondary  effects  of 
existing  paralyses.  Operative  deaths  may  be  due  to  sudden 
evacuation  of  cerebrospinal  fluid.  Meningitis  through  wound 
infection  may  occur. 

Cervical  Spondylitis. — The  abscess  should  be  emptied  early. 
This  may  be  done  through  a  small  incision,  in  order  to  avoid 
entrance  of  pus  into  the  glottic  opening,  or  the  abscess  may 
be  incised  freely  with  the  head  in  the  dependent  head  position 
of  Rose.  The  walls  of  the  abscess  contain  the  constrictor 
muscles  of  the  pharynx;  hence,  their  elasticity  is  such  as  to 
lead  to  rapid  emptying  and  collapse.  This  favors  early  resolu- 
tion, the  healing  process  frequently  being  completed  in  a  re- 
markably short  space  of  time. 

In  the  further  treatment  of  Pott's  disease  in  the  cervical 
region  it  will  be  necessary  to  apply  some  form  of  support  for 
the  head  and  vertebral  column.  This  may  be  accomplished 
by  the  use  of  a  jury  mast  attached  to  a  plaster-of -Paris  jacket 
(Fig.    200),    by    an    anteroposterior    support    with    head-piece 


OPERATIONS    ON    THE    VERTEBRAL    COLUMN 


545 


(Taylor,  Fig.  201),  by  a  padded  leather  collar  (Thomas,  Fig.  202), 
or  by  a  brass  wire  collar  (Burrell,  Fig.  203),  or  Volkmann's 
method  of  extension  in  the  recumbent  position  may  be  emploved 
(Fig.  204). 


Fig.  200. — Jury  mast. 
(Fowler's  Surgery.) 


Fig.     201. — Anteroposterior     support 
with  head-piece.     (Fowler's  Surgery.) 


Tuberculous  Spondylitis. — The  mechanic  treatment  is  of  the 
highest  importance.  Its  application  should  not  be  delayed 
after  the  discovery  of  the  disease.  While  it  cannot  correct 
already  existing  kyphosis,  on  account  of  the  processes  of  con- 
solidation which  have  already  taken  place,  progressive  deformity 
is  prevented  by  arrest  of  the  disease.  Two  types  of  appliance 
may  be  mentioned,  the  one  a  solid  fitting  corset  or  cuirass  of 
plastic  material,  while  the  patient  is  suspended  (Sayre,  Fig.  205) 

35 


546 


OPERATING    ROOM    AND    THE    PATIENT 


Fig.  202. — Padded  leather  collar.       Fig.  203. — Burrell's  brass  wire  collar. 
(Fowler's  Surgery.)  (Fowler's  Surgery.) 


Fig.   204. — Volkmann's  method   of  extension  in  the  recumbent  position. 

(Fowler's  Surgery.) 


OPERATIONS    ON    THE    VERTEBRAL    COLUMN 


547 


or  while  he  is  lying  supine  in  a  hammock  in  a  position  tending 
to  correct  the  deformity  (Richard  Davy,  Fig.  207),  and  the 
other  a  brace  whose  object  is  to  open  the  angle  anteriorly  placed 
at  the  kyphosis  and  thus  relieve  the  pressure  on  the  diseased 


Fig.  205. — ^Patient  suspended, 
ready  for  plaster-of-Paris  jacket 
(Sayre.)     (Fowler's  Surgery.) 


Fig.  206.— Taylor's  brace  for  Pott's 
disease.      (Fowler's  Surgery.) 


bodies  of  the  vertebrae  (Taylor).  The  first,  appliance  may  be 
made  either  of  plaster  of  Paris  or  of  poroplastic  felt  material, 
the  second  appliance  of  light  rods  of  steel  with  properly  fitted 
and  padded  bands  of  webbing  and  leather  adjusted  and  held 
in  position  by  straps  and  buckles  (Fig.  206). 


548  OPERATING    ROOM    AND    THE    PATIEXT 

The  plaster-of -Paris  jacket  is  applied  either  while  the  patient 
is  suspended  or  while  he  is  lying  in  a  hammock.  A  seamless 
knitted  shirt  of  wool  is  placed  next  to  the  skin,  with  layers  of 
wadding  or  lamb's  wool  to  protect  bony  prominences  from 
undue  pressure.  The  rolls  of  plaster-of -Paris  bandage  wetted 
in  weak  alum  water  are  circularly  applied  in  successive  layers, 


Fig.  207. — Hammock  suspension  for  application  of  plaster-of-Paris  jacket. 

(^Fowler's  Surgery.) 

reaching  from  below  the  line  of  both  iliac  crests  upward  to  the 
axillae.  Strips  of  the  bandage  should  be  curved  upward  behind 
and  in  front  to  gain  additional  support.  Vertically  applied 
strips  either  of  pasteboard  or  of  perforated  tin  are  incorporated 
in  the  jacket  between  its  laj^ers  to  strengthen  the  apparatus. 
When  the  jacket  is  sufficiently  hardened,  the  patient  is  lowered 


Fig.  20S. — Plaster-of-Paris  jacket  applied.      (Fowler's  Surgerj-.) 

and  the  upper  edge  at  the  axillae  trimmed  so  as  to  prevent 
excoriations.  If  the  hammock  is  used  (Fig.  208),  it  should  be 
made  of  cross-barred  crinoline  or  twilled  Canton  flannel,  and 
the  portion  beneath  the  jacket  allowed  to  remain  m  situ,  the 
edges  above  and  below  the  jacket  being  trimmed  down  and 
secured  by  a  few  additional  turns  of  a  bandage    (Fig.   209). 


OPERATIONS    OX    THE    VERTEBRAL    COLUMN 


549 


The  jacket  is  to  be  renewed  sufficiently  often  to  insure  cleanliness 
and  prevent  ulceration  at  prominent  points.  It  has  been  sug- 
gested that  the  jacket  be  cut  open  in  front  and  secured  by 
lacing;  this,  however,  lessens  the  efficiency  of  the  apparatus. 

Poroplastic  felt  corsets  have  been  employed,  particularly  in 
Germany.  Models  of  different  sizes  and 
shapes  representing  the  more  common 
forms  of  the  disease  at  different  periods 
of  life,  are  made,  and  on  these  a  poro- 
plastic  material,  the  basis  of  which  is 
woolen  fiber  and  gum  shellac  dissolved 
in  alcohol,  is  molded  in  the  shape  of  a 
cuirass.  When  needed,  one  of  these  is 
selected,  softened  by  heating,  and  ap- 
plied to  the  patient  while  suspended, 
burning  of  the  skin  being  prevented  by 
first  enveloping  the  trunk  in  an  accur- 
ately applied  wetted  muslin  bandage. 
The  corset  is  secured  in  position  by  turns 
of  a  roller  until  it  cools,  when  it  may  be 
removed,  its  edges  lined  with  chamois 
leather  to  prevent  chafing,  and  eyelet 
holes  or  shoe  hooks  placed  in  position 
for  lacing. 

The  indications  governing  the  surgeon's 
choice  in  the  use  of  these  systems  of 
support  will  depend  on  the  location  of  the 
disease.  In  Pott's  disease  high  up  in 
the  dorsal  region,  the  plaster-of-Paris 
jacket  or  the  poroplastic  felt  corset 
answers  the  purpose.  In  the  middle  and 
lower  dorsal,  as  well  as  in  the  lumbar 
region,  the  Taylor  type  of  support  will  be  preferable.  Care 
should  be  taken  that  the  appliance  is  kept  properly  adjusted 
and  renewed  as  the  child  outgrows  it.  The  poroplastic  corset 
is  also  employed  after  the  plaster-of-Paris  jacket  during  con- 
valescence (Golding  Bird). 

These  supports  permit  the  patient  to  walk  about.     In  case  he 


Fig.  209.— Jacket  fin- 
ished by  trimming  away 
hammock  and  turning 
up  and  securing  its  edges. 
(Fowler's  Surgery.) 


550 


OPERATING  ROOM  AND  THE  PATIENT 


is  compelled  to  maintain  the  recumbent  positon  for  any  length  of 
time,  or  for  night  use,  an  apparatus  designed  for  this  purpose 
may  be  used  (Schapp's  Fig.  210).  Extension  may  be  applied  by 
means  of  a  weight  and  pulley.  The  latter  is  more  frequently 
used  for  Pott's  disease  in  the  cervical  region. 

The  constitutional  treatmeyit  includes  medicinal  and  dietetic 
measures  and  fresh  air.     Patients  should  be  kept  out  of  doors  as 


Fig.  210. — Schapps's  recumbent  apparatus  for  the  treatment  of  Pott's 
disease.  A,  Stretched  canvas  laced  to  the  frame  by  stout  cords;  B,  cushions 
stuffed  with  hair  between  which  the  bony  projection  rests;  C,  padded  straps 
of  webbing  arranged  to  pass  around  the  shoulders  and  through  the  axillae. 
(Fowler's  Surgery.) 


much  as  possible.  Iron,  cod-liver  oil,  and  the  most  easily  digested 
as  well  as  the  most  nourishing  food  should  be  given.  Much  will 
depend  on  the  healthful  character  of  the  patient's  surroundings. 

The  Treatment  of  Scoliosis. — Prophylactic  treatment  is  embraced 
in  the  care  of  the  general  health,  the  correction  of  anemic  con- 
ditions, the  selection  of  proper  chairs  and  writing-desks,  and  the 
furnishing  of  sufficient  and  properly  directed  light  while  at  work 
in  school.  Finally,  a  watchful  care  must  be  exercised  to  prevent 
parents  from  sacrificing  the  health  of  the  child  to  excessive  men- 
tal culture. 

General  Measures  of  Treatment. — The  cause  should  be  removed 


OPERATIONS    ON    THE    VERTEBRAL    COLUMN  551 

where  it  can  be  ascertained.  The  extremities  should  be  equalized 
by  wearing  a  high  shoe;  change  of  occupation  and  methods  of 
recreation  are  to  be  insisted  on  and  a  proper  sitting  position,  or 
attitude,  while  standing  or  walking  is  to  be  advised.  The  general 
health  should  be  carefully  inquired  into,  and  remedies  adminis- 
tered that  are  calculated  to  correct  any  existing  constitutional 


Fig.  211.— Shaffer's  brace  applied.     (Fowler's  Surgery.) 

vice  and  restore  the  health  and  strength,  such  as  cod-liver  oil, 
preparations  of  iron,  iodin,  and  the  phosphates. 

Correction  of  the  Deformity.— The  most  important  means^at  our 
command  for  this  purpose  are  embraced  in  properly  directed 
gymnastic  exercises.  The  results  of  treatment  will  depend 
largely  on  how  thoroughly  the  patient  appreciates  the  importance 
of  this  part  of  the  treatment  and  how  persistently  he  devotes 


552 


OPERATING    ROOM    AND    THE    PATIENT 


himself  to  the  task  of  carrying  it  out.  The  system  known  as  the 
Swedish,  when  the  exercises  are  administered  by  a  person 
thoroughly  familiar  with  the  method  as  taught  in  Sweden,  is  by 
far  the  best.  In  addition  to  these  dumb-bell  exercises  or  self- 
suspension  by  Sayre's  apparatus,  should  be  practised,  or  the 
horizontal  bar  should  be  used  several  times  a  day;  the  patient 

should  lie  down  for  a  short 
time  after  each  seance.  In 
all  exercises  the  hand  on  the 
concave  side  should  be  kept 
on  a  higher  level  than  its 
fellow.  While  the  patient  is 
sitting  a  Volkmann's  Wedge- 
shaped  cushion  (Fig.  212)  is 
used  to  correct  the  deformity. 
When  the  patient  is  lying  on 
his  back,  a  hard  pillow  should 
be  placed  beneath  the  con- 
vexity. The  Sayre  head-piece 
for  self-correction  is  very 
useful. 

In  the  intervals  of  exercise 
and  recumbency  a  Shaffer 
modified  brace  (Young)  may 
be  worn  as  a  slight  support 
and,  in  addition,  as  a  reminder 
to  the  patient  of  the  necessity 
of  assuming  an  upright  posi- 
tion (Fig.  211).  The  object 
of  this  apparatus  and  its 
modifications  is  not  to  correct  the  deformity  by  attempting  to 
force  the  parts  into  a  correct  position.  If  worn  constantly  for 
this  purpose  and  the  exclusion  of  other  measures,  it  will  certainly 
be  productive  of  harm  by  restraining  the  action  and  development 
of  muscular  structures  already  weakened. 

Jaboulay  has  suggested  an  operation  for  correcting  the 
scoliosis  by  separating  the  ribs  from  the  sternum  and  permitting 
the  former  to  glide  over  the  latter.     For  instance,  in  case  of  a 


Fig.  212. — Volkmann's  wedge- 
shaped  seat  for  correcting  the  lumbar 
curve.     (Fowler's  Surgery.) 


INSTRUMENTS    AND    DRESSINGS    COMMONLY    EMPLOYED       553 

scoliotic  thorax  the  oblique  diameter  of  which  is  lengthened  from 
behind  forward  and  from  right  to  left,  and  shortened  in  the  op- 
posite direction,  a  separation  of  the  right  ribs  at  the  sternum 
would  cause  the  ends  of  the  latter  to  project  forward  and  inward. 
The  transverse  processes  of  the  dorsal  vertebrae  would  be  thereby- 
drawn  anteriorly  and  the  primary  vertebral  curves  corrected  by  a 
rotating  movement  on  the  costal  tubercle. 


CHAPTER   XXIII. 
INSTRUMENTS  AND  DRESSINGS  COMMONLY  EMPLOYED. 

I.  Articles  Required  for  all  Operations. 

Ligature  catgut,  medium  and  fine. 

Chromic  catgut,  medium  and  fine. 

Silk,  paraffin  silk,  or  linen  thread,  medium  and  fine. 

Silkworm  gut. 

Curved,  sharp-pointed  scissors  (for  cutting  ligatures  and  sutures). 

Long,  straight,  spear-pointed  needle  (for  skin  sutures). 

Medium-sized,  curved,  cutting-edge  needle  (for  skin  sutures). 

1  needle  holder. 

Soft  rubber  male  catheter.  No.  15  F." 
Glass  female  catheter. 

2  irrigators,  nozzles,  tubing,  various  sized  glass  connections. 
Safety-pins. 

Towel  clamps. 
Basin  for  siaecimens. 
Probe. 
Protectors. 
Towels. 

II.  Operations  upon  the  Scalp  (preparatory  to  trephining  and  for  operations 

upon  the  soft  jjarts). 
Junker  or  intubation  anesthesia  apparatus. 

1  three-foot   length   of   small-sized   rubber   tubing   and   tape    (for 

tourniquet) . 

2  scalpels. 

2  pairs  anatomic  forceps. 

12  Kocher  clamps. 

2  blunt  hook  retractors. 

18  medium-sized,  half -curved,  cutting-edge  needles  (threaded  in  pairs 

with  silkworm  gut). 
1  pair  curved-on-the-fiat,  blunt-pointed  scissors. 
,4  gauze  compresses. 

1  twelve-inch  square  of  nonabsorbent  cotton. 

2  three-inch  gauze  bandages. 


554  OPERATIXG    ROOM    AXD    THE    PATIEXT 

30  hand  sponges. 

12  stick  sponge  holders. 

in.  Trephining  and  Craniectomy  (in  addition  to  hst  II). 
1  cj'rtometer. 
1  periosteal  elevator. 

1  set  trephines. 
Gigh  saws. 

Sahne  irrigation  (to  keep  operative  field  clear). 

2  craniectomy  forceps. 
1  rongeur  forceps. 

1  set  large  chisels. 

1  mallet. 

Horseley  bone  wax. 

1  exploring  syringe  and  needle. 

Basin  of  saline  solution,  100°  F.  (for  temporarily  removed  bone). 

1  telephonic  brain  probe. 

Electric  battery  and  brain  electrodes. 

1  smaU,  narrow-bladed  scalpel. 

2  pairs  mouse-tooth  forceps. 

2  small,  full-curved,  cutting-edge  needles  (threaded  ■uith  fine  catgut, 

for  suturing  dura). 
Green-silk  protective  (for  drains). 
Bits  of  gauze  A^-ith  black  silk  thread. 
Gushing  vdre  Ugature  set. 
Blood-pressure  apparatus. 
2  three-inch  plaster-of-Paris  bandages,  salt  solution,  and  additional 

plaster. 

IV.  Excision  of  the  Trigeminus  (in  addition  to  Lists  II  and  III). 

2  Crile  clamps  (for  temporary  occlusion  of  the  carotids). 

1  brain  retractor  with  cold  electric  hght. 
50  small  stick  sponges. 

V.  Excision  of  the  Upper  Jaw. 

Junker's  apparatus  or  intubation  anesthesia. 
Tracheotomy  set  (List  XIII). 
Trendelenburg  cannula. 

2  tooth-forceps. 

2  fuU-beUied  scalpels. 

2  pairs  anatomic  forceps. 

1  periosteal  elevator. 

12  Kocher  clamps. 

1  pair  curved-on-the-flat,  blunt-pointed  scissors. 

1  set  large  chisels. 

1  mallet. 

1  lion-jaw  forceps, 

1  straight  bone-cutting  forceps. 

1  angular  bone-cutting  forceps. 

1  rongeur  forceps. 


INSTRUMENTS    AND    DRESSINGS    COMMONLY    EMPLOYED       555 

3  blunt  hook  retractors. 

2  Volkmann  sharp  spoons. 

2   medium-sized,   full-curved,    cutting-edge   needles   (threaded   with 

catgut  loop  sutures). 
1  twelve-inch  square  of  zinc  oxid  gauze. 
12  one-inch  zinc  oxid  packing  strips. 
12  medium-sized,  half-curved,  cutting-edge  needles  (threaded  in  pairs 

with  silkworm  gut) . 
Thermocautery  or  electric  cautery. 
1  medium-sized,  full-curved,  cutting-edge  needle  (threaded  with  silk 

for  tongue  suture) . 

4  gauze  compresses. 

1  twelve-inch  square  of  nonabsorbent  cotton. 

2  three-inch  gauze  bandages. 
12  stick  sponge  holders. 

50  stick  sponges. 
50  hand  sponges. 
lodoform-coUodion,  glass,  and  brush. 

VI.  Resection  of  the  Lower  Jaw  (in  addition  to  List  V). 

1  chain  saw  and  carrier. 

2  Gigli  saws. 

VH.  opening  the  Mastoid. 

2  scalpels. 

2  blunt  hook  retractors, 
1  self-retaining  retractor. 
1  periosteal  elevator. 
6  Kocher  clamps. 
1  set  mastoid  chisels. 
1  set  mastoid  gouges. 
1  mallet. 

1  small  trephine. 

2  Volkmann  sharp  spoons. 
1  small  sinus  curette. 

1  probe. 

1  grooved  director. 

1  pair  curved-on-the-flat,  blunt-pointed  scissors. 
Saline  irrigation. 
20  hand  sponges. 
30  small  stick  sponges. 
1  one-inch  zinc  oxid  packing  strip. 

4  medium-sized,  half-curved,  cutting-edge  needles  (threaded  in  pairs 
with  silkworm  gut) . 

3  gauze  compresses. 

1  twelve-inch  square  of  nonabsorbent  cotton. 

2  three-inch  gauze  bandages. 

Vm.  Harelip. 

1  tongue-forceps. 
1  tongue  depressor. 


556  OPERATING    ROOM    AND    THE    PATIENT 

1  mouth-gag. 

2  medium-sized,   half-curved,   cutting-edge  needles   (threaded  with 

silk,  for  traction  sutures). 
1  small,  narrow-bladed  scalpel. 

1  straight,  sharp-pointed  bistoury. 

2  pair  mouse-tooth  forceps. 

1  pair  curved-on-the-flat,  sharp-pointed  scissors. 

6  medium-sized,   haK-curved,    cutting-edge   needles    (threaded   with 

silk). 
6  small,  half-curved,  cutting-edge  needles  (threaded  with  silk). 

1  pair  small  hook  retractors. 
6  pointed  artery  clamps. 

12  hand  sponges. 
lodoform-coUodion,  glass,  and  brush. 

2  narrow  strips  of  adhesive  plaster  (to  relieve  tension). 

rx.  Staphylorrhaphy  and  Uranoplasty. 
1  Whitehead  gag. 

1  mouth-gag. 

2  cheek  retractors. 

1  tongue  depressor. 

12  stick  sponge  holders. 
50  stick  sponges. 

2  single  tenacula. 

1  narrow,  flat-bellied  scalpel  (for  section  of  levator  palati). 

1  small-bladded  scalpel  (for  paring  edges  of  cleft). 

2  pairs  long-handled,  mouse-tooth  forceps. 

1  pair  long-handled,  curved-on-the-flat,  sharp-pointed  scissors. 
1  dull-edged  periosteal  elevator  bent  at  a  right  angle. 
1  sharp-edged  periosteal  elevator  bent  at  a  right  angle. 

3  small,  half-curved,  cutting-edge  needles  (threaded  ■\\'ith  silk  loops, 

for  guide  suture). 
12  paraffin  silk  sutures. 
6  artery  clamps  (to  attach  to  sutures). 
1  long-handled  needle  holder. 

1  right  spiral  curved,  sharp-pointed  aneurysm  needle. 
1  left  spiral  curved,  sharp-pointed  aneurysm  needle. 

X.  Tonsillectomy. 

1  mouth-gag. 

1  tongue  depressor. 

1  pair  tenaculum  forceps. 

1  pair  long-handled,  curved-on-the-flat,  blunt-pointed  scissors. 

1  curved,  probe-pointed  bistoury. 

1  tonsillotome. 

2  stick  sponge  holders. 
12  stick  sponges. 

Ice-water,  tumbler,  and  pus  basin. 


INSTRUMENTS    AND    DRESSINGS    COMMONLY    EMPLOYED       557 

XI.  Adenoids. 

1  mouth-gag. 

1  tongue  depressor. 

2  Gottstein  curettes. 

1  pair  Lowenbury's  forceps. 

6  sponge  holders. 

20  stick  sponges. 

1  uvula  retractor. 

1  No.  20  F.  sound. 

Solution  of  adrenalin  chlorid,  1  :  1000. 

XII.  Deviated  Septum.     . 

1  mouth-gag. 

1  tongue  depressor. 
6  sponge  holders. 
20  stick  sponges. 

Solution  of  adrenalin  chlorid,  1  :  1000. 

Small  pieces  of  cotton  on  wooden  applicators. 

2  Douglas  knives. 
1  Mial  saw. 

1  Curtis  saw. 

1  Bosworth  saw. 

1  elevator. 

1  pair  Asch's  scissors. 

1  pair  Asch's  compressors. 

1  Douglas  perforator. 

1  set  Asch's  splints. 

XIII.  Tracheotomy. 

1  full-bellied  scalpel. 
18  Kocher  clamps, 

2  hook  retractors. 

2  pairs  anatomic  forceps. 

2  single  tenacula. 

1  flat-bellied  scalpel. 

1  pair  curved-on-the-flat,  blunt-pointed  scissors. 

1  pair  curved-on-the-flat,  sharp-pointed  scissors. 

1  cartilage-cutting  forceps  (for  enlarging  tracheal  opening). 

1  set  tracheotomy  tubes. 

Tapes  for  tube. 

3  medium-sized,    half-curved,   cutting-edge  needles   (threaded  with 

silk). 
Flexible  applicator  and  absorbent  cotton. 
20  hand  sponges. 
20  small  stick  sponges. 
6  stick  sponge  holders. 

XIV.  Cervical  Adenectomy. 

1  small  flat  sandbag  (placed  under  the  shoulders  to  extend  the  neck). 

2  scalpels  (dissecting  handles). 


558  OPERATING    ROOM    AND    THE    PATIENT 

24  Kocher  clamps. 

12  pointed  artery  clamps. 

2  pairs  anatomic  forceps. 

2  pairs  curved-on-the-flat  blunt-pointed  scissors. 

2  small,  smooth  retractors. 

2  blunt  hook  retractors. 

2  Volkmann  sharp  spoons. 

6  medium-sized,  half-curved,  cutting-edge  needles  (threaded  in  pairs 
with  silkworm  gut) . 

2  long,  straight,  spear-pointed  needles  (threaded  with  silk  for  sub- 
cuticular sutures) . 

1  medium-sized,  half-curved,  cutting-edge  needle  (threaded  with  silk 

for  subcuticular  sutiu-es). 
12  stick  sponge  holders. 
50  stick  sponges. 
6  gauze  compresses  (shaken  out). 

2  one-inch  gauze  strips  (in  drainage  cases). 

2  four-inch  fenestrated  rubber  tubes  (in  drainage  cases). 

2  twelve-inch  squares  of  nonabsorbent  cotton. 

3  three-inch  gauze  bandages. 

2  three-inch  plaster-of -Paris  bandages  (in  cliildren). 

XV.  Goiter  (in  addition  to  Lists  XIII  and  XIV). 

2  aneurysm  needles  (threaded  ■v\dth  medium-sized  catgut). 

2  glass  drainage  spools. 

Thermocautery. 

XVI.  Cutthroat. 

Combine  Lists  XIII  and  XIV. 

XVII.  Occlusion  of  the  Carotids,  Temporary  or  Permanent. 
List  XIV,  minus  sharp  spoons  and  drainage. 
2  aneurysm  needles    (threaded  with  two  strands   of   medium-sized 

catgut) . 
2  Crile  clamps  (for  temporary  occlusion). 

Parafl&n  injection  syringe,  paraffin,  alcohol  lamp,  basin  of  hot  water 
(in  occlusion  of  terminals  of  external  carotid). 

XV 111.  Amputation  of  the  Breast  (radical  operation  for  carcinoma), 

1  flat  sandbag. 

2  large  protectors. 

1  arm  and  hand  protector. 

1  bandage  (for  securing  arm). 

24  towels. 

1  towel  wringer. 

Hot  sahne  in  pitcher  (for  hot  towels). 

3  full-bellied  scalpels. 

1  small  scalpel. 
50  artery  clamps. 

2  pairs  anatomic  forceps. 


INSTRUMENTS    AND    DRESSINGS    COMMONLY    EMPLOYED       559 

2  pairs  curved-on-the-flat,  blunt-pointed  scissors. 

1  pair  blunt  hook  retractors. 

1  pair  small,  smooth  retractors. 

1  aneurysm  needle. 

1  single  tenaculum. 

50  large,  half-curved,  cutting-edge  needles  (threaded  in  pairs  with 
silkworm  gut). 

1  long,  straight,  spear-pointed  needle  (threaded  with  silk  for  sub- 
cuticular suture). 

1  skin-grafting  set  (List  LXXX). 
75  hand  sponges. 

12  gauze  compresses  (shaken  out). 

2  squares  nonabsorbent  cotton. 
1  breast  binder. 

1  three-inch  Ganton-flannel  bandage. 

XIX.  Empyema  (resection  of  rib). 

1  flat  sandbag. 
Exploring  syringe. 
Stethoscope. 

2  scalpels. 

12  artery  clamps. 
2  blunt  hook  retractors.  . 
1  periosteal  elevator. 
1  costotome. 
.  1  angular,  bone-cutting  forceps. 
1  rongeur  forceps. 

1  bone-grasping  forceps. 

2  Volkmann  sharp  spoons  (in  caries  cases). 

1  pair  curved-on-the-flat,  blunt-pointed  scissors. 

1  pointed  artery  clamp  (for  opening  pleura). 

1  blunt  curette. 

6  stick  sponge  holders. 

20  stick  sponges. 

20  hand  sponges. 

1  eight-inch  large-caliber  drainage  tube  and  glass   connection   (for 

subaqueous  drainage). 
8  medium-sized,  half-curved,  cutting-edge  needles  (threaded  in  pairs 

with  silkworm  gut). 
1  medium-sized,    half-curved,    cutting-edge   needle    (threaded   with 

silk  to  retain  tube  in  place). 
Boro-salicylic  and  saline  irrigation  (in  case  of  fibrinous  masses). 

3  gauze  compresses  (slit  to  allow  tube  to  emerge). 

4  adhesive  plaster  taped  straps. 
1  chest  binder. 

ABDOMINAL  OPERATIONS. 

XX.  Accessories  (extraabdominal) . 

1  laparotomy  sheet  or  two  protectors. 


560  OPERATING    ROOM    AND    THE    PATIENT 

XXI.  Laparotomy  Incision  (making). 

2  single  tenacula  (to  steady  the  skin). 

1  skin  knife,  small-bellied.  * 

2  pairs  anatomic  forceps. 
6  pairs  arter\'  clamps. 

1  pair  curved-on-the-flat,  blunt-pointed  scissors. 
1  pair  narrow  retractors. 

XXII.  Laparotomy  Incision  (retraction). 

1  self-retaining  retractor,  3  sets  of  blades. 

2  medium-sized  retractors. 
2  large  retractors. 

2  small  retractors. 

XXm.  Accessories  (intraabdominal). 
12  crash  laparotomy  sponges. 
12  gauze  laparotomy  sponges. 
50  stick  sponges. 
12  stick  sponge  holders. 
Woelfler's  solution  and  medicine  dropper. 
1  Kgature  carrier. 
1  \-isceral  grasping  forceps. 
1  basin  of  hot  bichlorid. 
1  basin  of  hot  saline. 
Towels,  towel  wringer,  and  pitcher  of  hot  saline. 

XXIV.  Articles  Required  in  Drainage  Cases. 

Equal  parts  hydrogen  peroxid  and  sterile  water  (can  be  used  slightly 
warm) . 

1  Chamberlain  douche  nozzle. 
Sahne  solution,  120°  F. 

2  curved,  fenestrated,  glass  drainage  tubes. 
Plain  A^icking. 

Cigarette  drains. 

Zinc  oxid  'U'icking. 

Gauze  strips,  two  and  four  inches  ^\-ide. 

Rubber  dam  (to  shp  over  tubes  and  to  protect  wound  dressing). 

Rubber  tubing  (in  gall-bladder  cases  and  for  lateral  drain  in  appen- 
dicitis %\-ith  abscess). 

1  uterine  dressing  forceps. 

1  narrow-bladed  scalpel  (for  making  accessory  drainage  opening). 

1  straight,  blunt-pointed  bistoury  (for  making  accessory  drainage 
opening) . 

1  pair  long-handled,  sharp-pointed,  curved  scissors  (for  vaginal 
drainage). 

1  pair  long-handled,  blunt-pointed,  curved  clamps  (for  vaginal 
drainage). 

1  large  glass  syringe. 

1  vulvar  pad  and  T-bandage  in  cases  drained  per  vaginam. 


INSTRUMENTS    AND    DRESSINGS    COMMONLY    EMPLOYED       561 

XXV.  Laparotomy  Incision  (closing). 

18  large,   half-curved,   cutting-edge  needles   (threaded  in  pairs  with 

silkworm  gut). 
12  artery  clamps. 

8  Halstead  clamps  for  the  peritoneum. 
1  pair  curved-on-the-flat,  blunt-pointed  scissors. 

1  medium-sized,    half-curved,    round    needle    (threaded    with    loop 

suture  of  catgut,  for  suture  of  peritoneum). 

2  medium-sized,   half-curved,    cutting-edge   needles    (threaded   with 

loop  sutures  of  chromic  gut,  for  aponeurosis  suture  and  muscle 

suture). 
1  long,    straight,    spear-pointed    needle    (for    subcuticular    suture) 

(threaded  with  linen  thread  or  silk). 
10  rubber  bolsters. 
1  one-inch  gauze  strip  (as  a  subcuticular  drain  in  fat  patients). 

XXVI.  Laparotomy  Incision  (dressing). 
4  compresses  of  plain  gauze. 

1  packet  of  nonabsorbent  cotton. 
6  adhesive  plaster  taped  straps. 

1  binder. 

18  safety-pins. 

2  perineal  straps. 

XXVII.  Appendectomy:     (A)  in  acute  cases,  in  addition  to  Lists  XX  to 

XXVI,  inclusive. 
2  small,  round  retractors. 
1  ligature  carrier  (armed  with  catgut  for  mesoappendix). 

1  small,'  round  needle  threaded  with  paraffin  silk   (for  first  purse- 

string)  . 

2  small,  half-curved,  round  needles  (threaded  with  chromic  gut  for 

purse-strings  or  Lembert  suture). 
Thermocautery  (knife  or  pointed  tip). 
CarboUc   acid,    glass,    and    sterilized    wooden    tooth-picks    (in    case 

thermocautery  fails  to  work). 
Special  forceps  for  grasping  and  inverting  appendical  stump. 
(B)       Appendectomy  in  the  interval,  as  above  except  List  XXIV. 

XXVIII.  Oophorectomy,  Salpingo -oophorectomy  (in  addition  to  Lists  XX 

to  XXVI,  inclusive). 

1  ovary  forceps. 

4  Keith  clamps,  light  weight  (for  deeply  situated  bleeding  points). 

2  medium-sized,  round  needles  (threaded  with  catgut  loop  sutures 

to  cover  in  raw  surfaces). 
4  strands  braided  catgut  (placed  in  pairs  on  ligature  carrier). 
Thermocautery,  pointed  tip  (to  destroy  any  remaining  lining  of  tube 

at  uterine  end). 

XXIX.  Extrauterine  Pregnancy  (in  addition  to  List  XXVIII). 
Saline  infusion  (List  LXXXII). 

1  large  Chamberlain  douche  nozzle. 
36 


562  OPERATING    ROOM    AND    THE    PATIENT 

Oxygen  for  intraperitoneal  introduction. 

1  one-gallon  pitcher. 

Saline  solution,  110°  F. 

4  gauze  compresses  (to  absorb  blood). 

XXX.  Hysterectomy  (in  addition  to  Lists  XX  to  XXIII,  inclusive,  that  part 

of  XXIV  referring  to  vaginal  drainage,  and  Lists  XXV  and 
XXVI). 

1  eight-pronged  tenacula  forceps. 
4  braided  catgut  ligatures. 

4  Keith  clamps  (heavy). 
4  Keith  clamps  (medium). 
4  Keith  clamps  (light). 

2  medium-sized,  half-curved,  round  needles   (threaded  with  catgut 

loop  sutures  to  cover  in  raw  surfaces). 

Thermocautery,  pointed  tip  (to  disinfect  cervical  canal  in  supra- 
vaginal amputation  of  uterus). 

Long  catgut  ligatures  (medium  size  for  deeply  situated  bleeding 
points). 

1  aneurysm  needle. 

XXXI.  Resection  of  Intestine  (in  addition  to  Lists  XX  to  XXIII,  inclusive, 

and  Lists  XXV  and  XXVI). 
4  intestinal  clamps  (blades  armed  with  rubber  tubing). 
4  tapes. 

1  small,  fuU-belHed  scalpel. 
1  pair  straight,  sharp-pointed  scissors. 

4  half-curved,  round  needles  (threaded  with  silk  for  guy  sutures). 
4  straight,  round  (cambric)  needles  (threaded  with  fine  paraffin  silk). 

1  ligature  carrier. 

10  strands  of  medium-sized  catgut  for  mesentery. 

2  medium-sized,  full-curved,  round  needles  (threaded  with  catgut  for 

mesentery) . 
1  set  Murphy  buttons. 
1  set  Chlumsky  buttons. 

1  set  McGraw's  elastic  ligatures  (used  only  in  very  emergent  cases). 
Towel  wringer,  towels,  pitcher  of  hot  saline. 

XXXII.  Ileocolostomy. 

Same  lists  as  for  resection  of  intestine. 

XXXIII.  Inguinal  Colostomy  (in  addition  to  Lists  XX  to  XXIII,  inclusive, 

and  Lists  XXV  and  XXVI). 
First  stage: 

20  medium-sized,  half-curved,  round  needles  (threaded  with  siik). 

Silver  wire  (for  occlusion  ligature). 
Second  stage: 

2  pairs  mouse-tooth  forceps. 

1  pair  straight,  sharp-pointed  scissors. 


INSTRUMENTS    AND    DRESSINGS    COMMONLY    EMPLOYED       563 

1  straight,  probe-pointed  bistoury. 

1  pus  basin. 

10  hand  sponges. 

2  paper  wool  pads. 

1  abdominal  binder. 

XXXrV.  Gastrotomy,  for  foreign  body  (in  addition  to  Lists  XX  to  XXIII, 

inclusive,  and  Lists  XXV  and  XXVI). 

2  medium-sized,  half-curved,  round  needles  (threaded  with  silk  for 

guy  sutures). 
1  narrow-bladed  scalpel. 
1  pair  straight,  sharp-pointed  scissors. 
6  slender-pointed  clamps. 

1  smooth-bladed  grasping  forceps. 

2  medium-sized,    full-curved,    round    needles    (threaded    with    loop 

sutures  of  fine  chromic  gut,  for  mucous  membrane  sutures). 
2  straight,  round  (cambric)  needles  (threaded  with  paraffin  silk,  for 
Lembert  sutures). 

XXXVo  Gastrostomy,  permanent  stomach  fistula  (in  addition  to  Lists  XX 
to  XXIII,  inclusive,  and  Lists  XXV  and  XXVI). 
15  medium-sized,  half-curved,  round  needles  (threaded  with  paraffin 

silk). 
1  narrow-bladed  scalpel. 

1  pair  straight,  sharp-pointed  scissors. 

2  medium-sized,    half-curved,    round    needles    (threaded    with    fine 

chromic  gut  loop  sutures,  for  mucous  membrane). 
1  soft-rubber  catheter,  No.  24  F. 
1  twelve-inch  square  of  green-silk  protective  (sHt  to  allow  tube  to 

emerge). 

XXXVI.  Gastrectomy  (in  addition  to  Lists  XX  to  XXIII,  inclusive,  and 

Lists  XXV,  XXVI,  and  XXXVII). 

1  ligature  carrier. 

18  medium-sized  catgut  ligatures. 

2  medium-sized,    half-curved,    round    needles    (threaded    with    fine 

catgut  loop  sutures. 

1  long-b laded  stomach  clamp  (jaws  armed  with  rubber  tubing). 

6  medium-sized,    half-curved,    round    needles    (threaded    with    fine 
chromic  catgut,  for  mucous  membrane). 

2  medium-sized,  half-curved,  round  needles  (threaded  with  paraffin 

silk,  for  Lembert  sutures). 

XXXVII.  Gastroenterostomy,  posterior  (in  addition  to  Lists  XX  to  XXIII, 

inclusive,  and  Lists  XXV  and  XXVI). 
1  blunt-pointed  anatomic  forceps  (for  separating  mesocolon). 
1  set  gastroenterostomy  clamps. 
4  medium-sized,    full-curved,    round  needles  (threaded  with  catgut 

for  suturing  mesocolon  to  stomach). 


564  OPERATING    ROOM    AND    THE    PATIENT 

2  needle  holders  (the  nurse  arms  one  while  the  othe'-  is  in  use) . 
2  intestinal  clamps  (jaws  armed  with  rubber  tubing). 

1  small-bladed  scalpel  (for  marking  out  visceral  openings). 

2  medium-sized,  half-curved,  rovmd  needles  (threaded  with  paraffin 

silk,  eighteen-inch  lengths,  for  continuous  Lembert  sutures). 

2  pairs  mouse-tooth  forceps  (for  steadying  intestines  and  stomach 

while  incising). 
1  pair  straight,  sharp-pointed  scissors  (for  \'isceral  incisions). 

3  mosquito  clamps. 
6  Kocher  clamps. 

1  medium-sized,  half-curved,  round  needle  (threaded  with  fine 
chromic  gut  loop  suture,  for  overcasting  cut  edge  of  intestine 
and  stomach). 

1  medium-sized  Chlumsla,'  button  (for  lateral  intestinal  anastomosis). 

2  straight,  round  (cambric)  needles  (for  closing  lateral  anastomosis 

openings  in  intestine  up  to  each  half  of  button.) 

1  SLlver-A\'ire    Ugature,    medium    weight,    twelve-inch    length    (for 

occlusion  suture). 

2  slender-bladed  clamps  (for  fastening  wire.) 

XXXVm.  Cholecystostoiny  (in  addition  to  Lists  XX  to  XXIII,  inclusive, 
and  Lists  XXV  and  XXVI). 

1  large,  smooth  retractor  (for  liver). 

2  medium-sized,  full-curved,   cutting-edge    needles    (threaded   with 

silk  for  guy  sutures). 

1  aspirating  syringe  and  needle. 

1  narrow-bladed  scalpel. 

1  medium-sized  scoop. 

1  small  curette. 

1  Blake  stone-grasping  forceps. 

1  flexible  duct  probe. 

1  gall-bladder  tucker. 

6  medium-sized,  full-curved,  cutting-edge  needles  (threaded  with 
chromic  gut,  to  secure  drainage  tube  to  gall-bladder). 

1  twelve-inch  rubber  tube. 

1  medium-sized,  half-curved,  cutting-edge  needle  (threaded  with 
chromic  gut,  used  as  a  purse-string  for  securing  inverted  gall- 
bladder to  tube). 

1  split  tube  for  additional  drainage. 

1  twelve-inch  square  of  rubber  dam  (to  protect  wound  dressing). 

XXXIX.  Cholecystectomy  (in  addition  to  Lists  XX  to  XXIII,  inclusive, 
and  Lists  XXV  and  XXVI). 

2  medium-sized,  full-curved,  cutting-edge  needles  (threaded  with  silk, 

for  traction  sutures). 
1  small  scalpel  (dissecting  handle). 

1  medium-sized  scoop. 
Thermocauterv',  knife  tip. 

2  braided  catgut  ligatures. 

1  one-inch  zinc  oxid  drainage  strip. 


INSTRUMENTS    AND    DRESSINGS    COMMONLY    EMPLOYED       565 

XL.  Cholecystenterostomy  (in  addition  to  Lists  XX  to  XXIII,  inclusive,  and 
Lists  XXV  and  XXVI). 

1  small  scalpel. 

2  pairs  mouse-tooth  forceps. 

2  medium-sized,  full-curved,  round  needles  (threaded  with  silk  for 

guy  sutures). 
2  intestinal  clamps  (jaws  armed  with  rubber  tubing). 
1  pair  straight,  sharp-pointed  scissors. 

1  small  Murphy  button. 

2  medium-sized,  full-curved,  round  needles  (threaded  with  silk,  to 

close  anastomosis  openings  up  to  each  half  of  button). 
4  medium-sized,  half-curved,  round  needles  (threaded  with  silk  for 

supporting  sutures). 
1  one-inch  zinc  oxid  gauze  drainage  strip. 

XLI.  Abdominal  Cysts  (in  addition  to  Lists  XX  to  XXIII,  inclusive,  and 
Lists  XXV  and  XXVI). 

1  large  trocar,  cannula,  tube,  and  pitcher. 

2  medium-sized,  half-curved,  round  needles  (threaded  with  catgut 

loop  sutures,  in  case  cyst-wall  is  to  be  attached  to  the  incision) . 
Thermocautery. 
24  Kocher  clamps. 
6  light-weight  Keith  clamps. 

1  ligature  carrier. 

2  aneurysm  needles  (threaded  with  catgut). 
2  braided  catgut  ligatures. 

2  medium-sized,  half-curved,  round  needles  (threaded  with  catgut 

loop  sutures,  for  covering  in  raw  surfaces). 
2  four-inch  zinc  oxid  gauze  strips. 

XLII.  Cesarean  Section  (in  addition  to  Lists  XX  to  XXIII,  inclusive,  and 

Lists  XXVI  and  LXXXII). 
1  large,  full-bellied  scalpel. 
1  three-foot  length  of  rubber  tubing. 
12  Kocher  clamps. 
6  light-weight  Keith  clamps. 
Sahne  solution,  120°  F. 
Braided  silk  for  umbilical  cord. 

1  Large  pad  of  gauze  and  towels  (to  protect  peritoneum) . 
6  large,  half-curved,  round  needles  (threaded  with  catgut,  for  uterine 

sutures) . 
12  medium-sized,  half-curved,  round  needles  (threaded  with  chromic 

gut  for  uterine  sutures). 
1  vulvar  pad  and  T-bandage. 
1  breast  binder. 
Fluid  extract  of  ergot. 
For  the  baby:   Tape,  hot  and  cold  baths;  ohve  oil,  toilet  powder,  and 

a  warm  blanket. 


566  OPERATING    ROOM    AND    THE    PATIENT 

XLIII.  Ventral  and  Umbilical  Hernia  (in  addition  to  Lists  XX  to  XXIII, 
inclusive,  and  Lists  XXV  and  XXVI;  in  strangulated  cases 
List  XXXI). 
8  medium-sized,  half-curved,   cutting-edge  needles   (threaded  with 
kangaroo  tendon  or  chromic  gut). 

XLIV.  Inguinal  Hernia  (if  strangulated  include  List  XXXI). 
2  large  protectors. 

1  one-inch  gauze  bandage  for  penis. 
6  towels. 

2  full-bellied  scalpels  (dissecting  handles). 

1  straight,  probe-pointed  bistoury. 

2  pairs  anatomic  forceps. 
18  artery  clamps. 

1  twelve-inch  tape  (for  retracting  cord). 

1  pair  curved-on-the-flat,  blunt-pointed  scissors. 

1  ligature  carrier. 

4  small  retractors. 

1  medium-sized,  half-curved,  round  needle   (threaded  with  medium- 

sized  catgut  for  transfixing  neck  of  sac). 

2  needle  holders  (the  nurse  arms  one  while  the  other  is  in  use). 

12  medium-sized,  half-curved,  round  needles  (threaded  with  kan- 
garoo tendon  or  chromic  gut  for  canal  aponeurotic  sutures). 

1  spatula  (for  retracting  posterior  wall  of  canal). 

1  medium-sized,  half-curved,  cutting-edge  needle  (threaded  with 
fine  catgut  loop  suture,  for  deep  layer  of  superficial  fascia). 

1  long,  straight,  spear-pointed  needle  (threaded  with  silk,  for  sub- 
cuticular .uture). 

12  stick  sponge  holders. 

30  hand  sponges. 

30  stick  sponges. 

1  small  hand  basin  (inverted  to  support  pelvis  while  applying  dress- 
ing; the  lirab  should  also  be  supported  to  relieve  strain  on  the 
sutures) . 

3  gauze  compresses. 

1  adhesive-plaster  strap  (placed  across  thighs  to  support  scrotum;  to 
protect  the  scrotum  a  folded  compress  is  placed  on  the  edge 
of  the  strap). 

1  twelve-inch  square  of  nonabsorbent  cotton. 

2  four-inch  muslin  bandages  (spica  of  groin). 

XLV.  Femoral  Hernia,  Fabricius  operation   (if  strangulated,  include  List 
XXXI). 
2  large  protectors. 
6  towels. 
2  full-bellied  scalpels. 

1  straight,  probe-pointed  bistoury. 

2  pairs  anatomic  forceps. 
12  artery  clamps. 


INSTRUMENTS    AND    DRESSINGS    COMMONLY    EMPLOYED       567 

1  medium-sized,  half-curved,  round  needle  (threaded  with  catgut, 

for  transfixing  neck  of  sac). 

2  small  retractors. 

1  round  retractor  (for  retracting  femoral  vessels) . 

6  medium-sized,  full-curved,  round  needles  (threaded  with  kangaroo 
tendon  or  chromic  gut,  for  suturing  Poupart's  ligament  to  the 
pectineus  muscle). 

2  needle  holders  (the  nurse  arms  one  while  the  other  is  in  use). 

1  medium-sized,  half-curved,  cutting-edge  needle  (threaded  with  fine 
catgut  loop  suture,  for  loose  cellular  tissue). 
'     1  long,  straight,  spear-pointed  needle  (threaded  with  silk  for  subcu- 
ticular suture). 

12  stick  sponge  holders. 

30  stick  sponges. 

30  hand  sponges. 

1  small  hand  basin  (see  Inguinal  Hernia). 

3  gauze  compresses. 

4  adhesive-plaster  taped  straps. 

2  four-inch  muslin  bandages  (spica  of  groin). 

XLVI.  Vaginal  Operations  (accessories). 
1  Kelly  pad. 
1  anus  protector. 
1  pail. 

1  perineal  sheet. 
Dusting  powder  to  apply  to  clitoris  after  separating  adhesions. 

XLVII.  Curettage  (in  addition  to  List  XLVI). 

1  self-retaining  speculum,  three  interchangeable  blades  (for  dorsal 

position). 
1  large  Sims'  speculum. 

1  self-retaining  and  expanding  Sims'  speculum  (when  operating  with- 

out assistants). 

2  curved  tenacula  forceps. 

1  cervix  cleaner  (applicator  wound  with  gauze  or  cotton). 

1  uterine  sound. 

1  small  dilator. 

1  large  dilator. 

1  polypus  forceps. 

1  medium-sized  dull  curette. 

1  medium-sized  sharp  curette. 

1  small,  sharp  curette  (for  curetting  cornua). 

6  stick  sponge  holders. 

1  pair  curved-on-the-flat,  blunt-pointed  scissors. 

20  stick  sponges. 

1  uterine  dressing  forceps. 

Normal  saline  solution,  120°  F.  (in  simple  cases). 

Boro-salicylic  solution,  120°  F.  (in  suspicious  cases). 

Bichlorid  solution,  120°  F.,  1  :  10,000  (in  septic  cases). 


568  OPERATING    ROOM    AND    THE    PATIENT 

Cervix  strip  (in  septic  cases). 

1  gauze  strip  four  inches  wide  for  vaginal  pack  (to  correct  displace- 
ments). 
1  paper-wool  vulvar  pad. 

1  T-bandage,  single. 
4  safety-pins. 

XLVin.  Trachelorrhaphy  (in  addition  to  Lists  XL VI  and  XL VII). 

2  lateral  vaginal  retractors. 
1  pair  hawksbill  scissors. 

1  scalpel. 

1  pair  tissue  forceps. 

1  pair  long-handled,  curved-on-the-flat,  sharp-pointed  scissors. 

30  stick  sponges. 

1  pair  anatomic  forceps  (to  hold  first  knot  of  sutures). 

10  straight  or  quarter  curved  cer^dx  needles  (threaded  with  medium- 
sized  chromic  gut). 

2  needle  holders  (the  nurse  arms  one  while  the  other  is  in  use). 
1  counterpressure  hook. 

10  artery  clamps. 

1  angle  cleaner  (similar  to  cer\dx  cleaner,  for  removing  clots  before 

tying  ligatures). 

XLIX.  Colporrhaphy,  anterior  and  posterior  (in  addition  to  Lists  XLVI  and 
XL  VII). 

2  lateral  vaginal  retractors. 
1  anterior  vaginal  retractor. 

4  medium-sized,  half-curved,  round  needles  (threaded  with  silk,  to 

serve  as  retractors). 
1  scalpel. 

1  pair  tissue  forceps. 

1  pair  curved-on-the-flat,  sharp-pointed  scissors. 
6  artery  clamps. 
4  medium-sized,   half-curved,    cutting-edge  needles   (threaded  •v\'ith 

chromic  gut). 

1  pair  anatomic  forceps. 
30  stick  sponges. 

L.  Colpotoray,    anterior   and   posterior    (in   addition   to    Lists   XLVI   and 
XL  VII). 

2  lateral  vaginal  retractors. 

1  intraperitoneal  blade  of  self-retaining  speculum. 

1  pair  long-handled,  curved-on-the-flat,  blunt-pointed  scissors 

1  needle  holder. 

'     2   medium-sized,   half-curved,   round  needles    (threaded  with   stout 
silk,  to  serve  as  guy  sutures). 
6  light-weight  Keith  clamps  (for  oophorectomy). 
4  braided  catgut  ligatures  (for  oophorectomy). 

2  medium-sized,   half-curved,    cutting-edge  needles    (threaded  with 


INSTRUMENTS    AND    DRESSINGS    COMMONLY    EMPLOYED       569 

catgut  loop  sutures,  for  securing  drainage  tube  or  suturing 

wound) . 
Gauze  drainage  strips,  two  inches  wide  (for  cellulitis  cases). 
Fenestrated  rubber  drainage  tubes   (three-fourths  inch  caliber,  for 

pus  cases). 
Small-sized  "horse  tracheotomy  tube"  (for  prolonged  drainage). 
Harrison's  rubber  drainage  tube. 
30  stick  sponges. 

LI.  Perineorrhaphy  (in  addition  to  Lists  XLIV  and  XL VII). 
1  pair  curved-on-the-flat,  sharp-pointed  scissors. 
1  pair  curved  on-the-flat,  blunt-pointed  scissors. 
1  full-bellied  scalpel. 
1  pair  tissue  forceps. 

1  needle  holder. 

6  medium-sized,    half-curved,    cutting-edge    needles    (threaded    in 
pairs  with  silkworm  gut). 

2  medium-sized,  half-curved,   cutting-edge  needles   (threaded   with 

chromic  gut  loop  sutures). 

1  medium-sized,    half-curved,    cutting-edge    needle  (threaded    with 

chromic  gut,  for  skin  and  mucous  membrane  suture). 
6  artery  clamps. 

2  four-inch  rubber  bolsters. 
30  stick  sponges. 

LII.  Urethral  Caruncle  (in  addition  to  Lists  XL VI  and  XL VII). 

2  lateral  retractors. 

Thermocautery  or  electric  cautery  (fine  tip). 

1  slender-bladed  knife. 

2  pairs  mouse-tooth  forceps. 
6  slender-pointed  clamps. 

12  small,  half -curved,  round  needles  (threaded  with  fine  silk). 

1  needle  holder. 

1  pair  slender,  sharp-pointed,  curved  scissors. 

1  rubber  catheter.  No.  20  F. 

12  artery  clamps  (to  use  on  sponge  sticks). 
30  small  stick  sponges. 

LIII.  Vaginal  Hysterectomy  (in  addition  to  Lists  XL VI  and  XL VII). 

2  lateral  vaginal  retractors. 
1  anterior  vaginal  retractor. 

1  intraperitoneal  blade  of  self-retaining  speculum. 

1  long-handled  scalpel. 

4  medium-sized,  full-curved,  round  needles  (threaded  with  stout  silk, 

for  traction  sutures). 
1  pair  long-handled,  curved-on-the-flat,  sharp-pointed  scissors. 
1  pair  long-handled,  curved-on-the-flat,  blunt-pointed  scissors. 
4  light-weight  Keith  clamps. 
4  medium-weight  Keith  clamps. 


570  OPERATING    ROOM    AXD    THE    PATIENT 

4  heaAy  Keith  clamps. 

4  curved  Pean  clamps. 

2  six-pronged  tenacula  forceps. 

5  Kocher  clamps. 

12  stick  sponge  holders. 

8  braided  catgut  ligatures. 

4  medium-sized,  half-curved,  round  needles  (threaded  with  catgut 

loop  sutures,    for    covering    in    raw    surfaces    and    suturing 

incision). 
2  zinc  oxid  gauze  strips  eight  inches  wide. 

LIV,  Fistula,    vesicovaginal,    rectovaginal    (in    addition    to    Lists    XL\T!, 
XL VII,  and  XLIX). 

2  paring  knives. 

4  smaU  half-curved  round  needles  threaded  with  silk. 

LV.  Circumcision. 

1  strong,  flat-ended,  silver  probe  (to  break  up  adhesions). 

3  arterj'  clamps. 

1  circumcision  clamp  (in  adults). 

1  pair  curved-on-the-flat,  sharp-pointed  scissors. 

2  pairs  mouse-tooth  forceps. 
1  pair  anatomic  forceps. 

6  small,  half-curved,  cutting-edge  needles  (threaded  ^^ith  fine  catgut). 
1  three-inch  iodoform  strip  gauze. 

12  hand  sponges. 

LVI.  Varicocele. 

1  one-inch  gauze  bandage  (wet  with  bichlorid,  for  penis). 

2  scalpels. 

2  pairs  anatomic  forceps. 

6  artery  clamps. 

2  aneurysm  needles  (threaded  with  medium-size  catgut  for  hgating 

veins). 
1  pair  curved-on-the-fiat.  blunt-pointed  scissors. 

1  pair  blunt  hook  retractors. 

2  pieces  of  tape. 

1  medium-sized,  half-curved,  cutting-edge  needle  (threaded  with 
fine  catgut  loop  sutiire,  for  sewing  vein-stumps  together). 

1  medium-sized,  curved,  cutting-edge  needle  (threaded  "ndth  medium- 
sized  chromic  gut,  for  suturing  skin  incision). 

1  medium-sized,  curved,  cutting-edge  needle  (threaded  with  fine 
catgut,  in  case  tunica  is  opened). 

12  hand  sponges. 

1  strip  of  adhesive  plaster  eighteen  inches  by  four  inches  (placed 
across  thighs  to  support  scrotum). 

1  gauze  compress,  folded  (to  protect  scrotum  from  edge  of  adhesive 
plaster  support). 

3  gauze  compresses. 


INSTRUMENTS    AND    DRESSINGS    COMMONLY    EMPLOYED       571 

1  small  hand  basin  (pelvic  support). 

1  twelve-inch  square  of  nonabsorbent  cotton. 

2  three-inch  gauze  bandages  (single  spica  of  groin) , 

LVII.  Hydrocele,  open  operation. 

1  curved,  sharp-pointed  bistoury. 

1  scalpel. 

12  artery  clamps. 

1  pair  curved-on-the-flat,  blunt-pointed  scissors. 

2  pairs  mouse-tooth  forceps. 

1  pair  small,  blunt  hook  retractors. 

12  hand  sponges. 

1  zinc  oxid  gauze  drainage  strip,  two  inches  wide. 

6  medium-sized,    half-curved,   cutting-edge   needles    (threaded   with 

silk  or  chromic  gut). 
1  adhesive-plaster  strip  for  scrotum  (see  Varicocele). 
1  gauze  compress,  folded  (see  Varicocele). 

3  gauze  compresses. 

1  twelve-inch  square  of  nonabsorbent  cotton. 

1  four-inch  gauze  bandage. 

LVIII.  Hypospadias  (methods  of  Anger  and  Duplay). 

2  small,  flat-bellied  scalpels. 
6  towels. 

2  pairs  small  mouse-tooth  forceps. 

1  pair  slender,  anatomic  forceps. 

6  slender-pointed  artery  clamps. 

1  pair  small,  curved-on-the-flat,  sharp-pointed  scissors. 

12  small,  half -curved,  round  needles  (threaded  in  pairs  with  fine  silk). 

6  small,  half-curved,  round  needles  (threaded  with  fine  silk). 

6  small,  half-curved,  round  needles  (threaded  with  fine  catgut). 

1  soft-rubber  catheter,  No.  14  F. 

1  gauze  compress,  shaken  out  (held  in  place  with  safety-pin). 

LIX.  Internal  Urethrotomy. 
6  towels. 

2  ounces  of  ohve  oil  in  a  glass. 
1  glass  piston  syringe. 

3  dozen  fihform  bougies. 
1  set  tunneled  sounds. 

1  urethrotome. 
1  complete  set  of  sounds. 
1  soft-rubber  catheter.  No.  20  F. 

Boro-sahcyhc  irrigation  and  glass  connection  to   fit   catheter   (to 
flush  out  urethra). 

4  weU-padded  pieces  of  basswood  four  inches  by  one-half  inch,  to 

sphnt  penis  in  case  of  severe  hemorrhage. 
1  one-inch  gauze  bandage  and  safety-pin  to  secure  si>hnt. 


572  OPERATING  ROOM  AND  THE  PATIENT 

LX.  Perineal  Section,  for  stricture  and  drainage,  in  addition  to  List  LIX. 
1  perineal  sheet. 
Trocar  and  cannula. 
1  set  lithotomy  staffs. 
1  full-bellied  scalpel. 
1  long,  grooved  director. 
1  straight,  probe-pointed  bistoury. 
1  perineal  director. 

1  gorget. 

2  blunt  hook  retractors  (when  dissection  of  urethra  is  necessary). 
6  artery  clamps. 

1  large  examining  cystoscope. 

1  slender  forceps  (to  aid  in  passing  perineal  tube). 

3  soft-rubber  perineal  tubes,  Nos.  32,  34,  36  F. 

1  large,  curved,  cutting-edge  needle  (threaded  mth  stout  silk  to 
secure  tube). 

3  medium-sized,  full-curved,  cutting-edge  needles  (threaded  with 
silk). 

20  hand  sponges. 

30  stick  sponges. 

12  stick  sponge  holders. 

Saline  irrigation  and  glass  connection  to  fit  perineal  tube. 

1  umbrella  tampon  (in  case  of  severe  bleeding).  This  is  made  by 
passing  the  perineal  tube  through  the  center  of  an  eight-inch 
square  double  thickness  of  gauze.  The  gauze  near  the  aper- 
ture in  it  is  sewn  fast  to  the  tube  at  a  point  which,  when  the 
tube  is  in  position^  Kes  just  mthin  the  bladder.  The  tube  is 
inserted  and  the  interior  of  the  umbrella  tightly  packed  with 
small  strips  of  gauze  the  ends  of  which  emerge  alongside  of 
the  tube. 

3  gauze  compresses  (with  apertures  cut  to  allow  passage  of  tube). 

1  T-bandage,  double. 

1  glass  connection  (to  attach  perineal  tube  to  rubber  tube  leading 

to  urine  bottle). 

LXI.  In  Impassable  Stricture  Cases:  Perineal  Section  Without  a  Guide  (in 

addition  to  List  LX). 

2  pairs  mouse-tooth  forceps. 

6  small,  half-curved,  round  needles  (threaded  with  silk,  to  aid  in 

retraction  and  to  identify  remains  of  urethra). 
1  needle  holder. 
1  pair  curved-on-the-flat,  sharp-pointed  scissors. 

1  long  silver  probe. 

2  single  tenacula. 


LXn.  In  Stone  Cases  (in  addition  to  List  LX). 
1  Thompson  searcher. 
1  set  of  stone-crushing  and  stone-grasping  forceps. 


INSTRUMENTS    AND    DRESSINGS    COMMONLY    EMPLOYED       573 

LXIII.  Prostatectomy,  perineal  (in  addition  to  List  LX). 
6  half-curved,  cutting-edge  needles. 
1  bifid  retractor  (Young). 

1  prostatic  retractor  (Young). 

2  lobe  forceps  (Young). 

2  narrow  retractors  (Young). 

1  posterior  retractor  (Young). 

1  blunt  dissector  (Young). 

1  pr.  long,  curved,  blunt-pointed  scissors. 

1  sharp  half-curved  hook. 

2  hemorrhoid  clamps. 

1  dressing  forceps. 

LXrV.  Suprapubic  Cystotomy. 

2  scalpels. 

2  blunt  hook  retractors. 

1  pair  curved-on-the-flat,  sharp-pointed  scissors. 

2  narrow-bladed  retractors. 

4  amall,  full-curved,  round  needles  (threaded  with  silk  for  guy 
sutures) . 

1  electric-light  bladder  retractor. 

1  electrocautery  set,  for  removing  tumors. 

1  set  of  stone  instruments  (List  LXII). 

4  small,  full-curved,  round  needles  (threaded  with  chromic  gut,  for 
suturing  bladder). 

1  soft-rubber  suprapubic  drainage  tube.  No.  40  F.,  with  glass  con- 
nection to  fit.  (This  is  attacAied  by  a  rubber  tube  to  a  Daw- 
barn  apparatus  at  the  bedside.) 

1  three-inch  zinc  oxid  gauze  packing  strip. 

2  narrow  strips  of  adhesive  plaster  (to  retain  tube  in  position). 
2  gauze  compresses. 

1  twelve-inch  square  of  nonabsorbent  cotton. 

1  abdominal  binder  (spUt  to  allow  passage  of  tube). 

2  perineal  straps. 
18  safety-pins. 

LXV.  Kidney  Incision    (for  exposing  kidney). 

1  oblong  sand  pillow  eighteen  inches  long,  twelve  inches  wide,  and 

eight  inches  thick,  covered  with  sterile  towel  or  anEdebohls' 
cushion. 

2  full-bellied  scalpels. 

2  pairs  anatomic  forceps. 

6  artery  clamps. 

2  pairs  curved-on-the-flat,  blunt-pointed  scissors. 

2  medium-sized  retractors,   one  with  six-inch  blade  and   one  with 

four-inch  blade  (for  deep  retracting). 
50  hand  sponges. 
30  stick  sponges. 
12  stick  sponge  holders. 


574  OPERATING    ROOM    AND    THE    PATIENT 

LXVl.  Kidney  Incision  (closing) . 

12  full-curved,  cutting-edge  needles  (threaded  in  pairs  with  silk- 
worm gut). 

1  long,  straight,  spear-pointed  needle  (threaded  -with  silk  for  subcu- 
ticular suture). 

1  gauze  strip  four  inches  wide  by  three  yards  long  (if  kidney  support 
is  needed). 

3  gauze  compresses. 

3  folded  towels  (to  serve  as  anterior  support  for  kidney). 

4  taped  adhesive-plaster  straps. 

1  twelve-inch  square  of  nonabsorbent  cotton. 

1  abdominal  binder. 

LXVn,  Kidney  Exploration  (in  addition  to  Lists  LXVI  and  LXVII). 

2  long,  blunt-pointed,  steel  pins  (hat-pins  with  ends  blunted). 
1  exploring  syringe  and  needle. 

Thermocautery  knife  (pointed  tip). 

1  flat-bellied  knife  with  dissecting  handle  (for  sphtting  or  removing 

capsule) . 
1  large,  fiat-bellied,  broad-bladed  knife  for  sphtting  kidney. 
1  special  forceps  for  compressing  pedicle  (jaws  armed  with  rubber 

tubing). 
6  long,  straight,  round  needles  (threaded  in  pairs  with  paraffin  silk, 

eighteen-inch  lengths,  for  through-and-through  sutures). 
6  medium-sized,  full-curved,  round  needles  (threaded  with  paraffin 

silk  for  hemostatic  sutures). 

1  ureteral  probe  (hollow). 

2  long,  silver  probes. 

LXVIII.  Nephrotomy  (in  addition  to  Lists  LXV,  LXVI,  and  LXVII). 

3  Keith  clamps. 

2  large,  dull  curettes. 

Saline  irrigation. 

Peroxid  and  sodium  bicarbonate  solution. 

1  pair  dressing  forceps. 

2  fenestrated  rubber  drainage  tubes. 

3  zinc  oxid  gauze  packing  strips. 

LXIX.  Kidney  Suspension  (in  addition  to  Lists  LXV  and  LXVI). 

6  artery  clamps  (for  traction  on  the  fatty  capsule). 

4  medium-sized,    half-curved,    round    needles    (threaded    with    silk, 

eighteen-inch  lengths,  for  suspension  sutures  in  pairs). 
4  medium-sized,  full-curved,  round  needles  (threaded  ^^ith  kangaroo 
tendon,  for  suspension  by  band  from  quadra tus  lumborum). 

LXX.  Nephrectomy  (in  addition  to  Lists  LXV  and  LXVI), 

2  long,  curved,  P6an  clamps. 

3  Keith  clamps. 

2  braided  catgut  Kgatures. 

1  ligature  carrier. 

1  pair  long,  curved-on-the-flat,  blunt-pointed  scissors. 


INSTRUMENTS    AND    DRESSINGS    COMMONLY    EMPLOYED       575 

OPERATIONS  UPON  THE  RECTUM  AND  ANUS. 

LXXI.  Fistula  in  Ano. 

1  perineal  sheet. 

2  silver  probes. 

1  wire  rectal  speculum. 

1  long,  grooved  director. 

1  scalpel. 

1  curved,  sharp-pointed  bistoury. 

1  curved,  blunt-pointed  bistoury. 

2  mouse-tooth  forceps. 

1  pair  curved-on-the-flat,  blunt-pointed  scissors. 

1  medium-sized  sharp  curette. 

2  blunt  hook  retractors. 
Hydrogen  peroxid. 

1  large  glass  syringe. 

12  artery  clamjDs. 

1  medium-sized,    half-curved,    cutting-edge   needle    (threaded    with 

catgut  for  circumsuture  in  case  of  troublesome  hemorrhage). 
1  large  umbrella  tampon. 
6  stick  sponge  holders. 
30  stick  sponges. 
1  2-grain  opium  suppository. 
Vaselin  for  anointing  suppositories. 
1  three-inch  strip  of  balsam-of-Peru  gauze. 
1  paper- wool  pad. 
1  T- 


LXXII.  Hemorrhoids  (combined  ligature  and  cautery  operation). 

1  perineal  sheet. 

1  rectal  speculum. 

6  large  hemorrhoid  clamps  (ring  clamps). 

6  small  hemorrhoid  clamps  (ring  clamps). 

1  pair  curved-on-the-flat,  blunt-pointed  scissors. 

6  large,  half-curved,  cutting-edge  needles  (threaded  with  eighteen- 

inch  lengths  of  catgut  for  transfixing  hemorrhoids). 
6  artery  clamps. 

1  thermocautery  (button  or  knife  tip). 
6  medium-sized,   half-curved,   cutting-edge  needles    (threaded   with 

catgut  for  use  as  a  purse-string  in  covering  in  raw  surfaces). 
1  2-grain  opium  suppository. 
Vaselin  for  anointing  suppositories. 

1  Kelsey  hemorrhoid  clamp  (in  simple  cautery  operations). 
30  stick  sponges. 
6  stick  sponge  holders. 
1  large  umbrella  tampon. 
1  paper-wool  pad. 
1  T-bandage,  double. 


576  OPERATING    ROOM    AND    THE    PATIENT 

XXXin.  Prolapsus  Recti  (suspension  of  rectum) . 
2  scalpels. 

2  pairs  anatomic  forceps. 
12  Kocher  clamps. 

1  pair  curved-on-the-flat,  blunt-pointed  scissors. 

3  blunt  hook  retractors. 
1  pair  tissue  forceps. 

1  large,  curved,  cutting-edge  needle  (threaded  with  chromic  gut 
or  kangaroo  tendon  for  circumsuture  of  rectum). 

6  medium-sized,  half -curved,  cutting-edge  needles  (threaded  with 
chromic  gut  or  kangaroo  tendon,  for  suspension  sutures  of 
rectum) . 

12  medium-sized,  half-curved,  cutting  needles  (threaded  with  silk- 
worm gut). 

3  gauze  compresses. 

1  T-bandage. 

LXXIV.  Extirpation  of  Rectum  by  the  Abdomino-perineal  Route  (in  addition 
to  Lists  XX  to  XXIII,  inclusive,  and  Lists  XXV  and  XXVI). 

1  ligature  carrier. 

2  heavy  silk  ligatures  (for  sigmoid). 

1  pair  straight,  sharp-pointed  scissors. 

10  eighteen-inch  lengths  of  catgut  (for  mesorectum). 

2  aneurysm  needles,  right  and  left  (threaded  with  catgut,  for  ligat- 

ing  internal  ihac  arteries). 
1  six-inch  iodoform  gauze  strip  (to  wrap  around  ends  of  sigmoid). 
12  medium-sized,   half-curved,  round  needles   (threaded  with   silk, 

for  artificial  anus). 

1  perineal  sheet. 

2  heavy  Keith  clamps. 
12  light  Keith  clamps. 

1  six-inch  zinc  oxid  gauze  strip. 

2  paper-wool  pads. 
Collodion,  brush,  and  glass. 
6  gauze  compresses. 

1  T-bandage. 


LXXV.  Resection  of  Joints. 

1  large  sheet. 

2  small  protectors. 
Hand  or  foot  bags. 

1  rubber  bandage. 

.    1  Esmarch  constrictor. 

2  scalpels. 

1  resection  knife. 

2  pairs  anatomic  forceps. 
24  artery  clamps. 

1  pair  curved-on-the-flat,  blunt-pointed  scissors, 
1  periosteal  elevator. 


INSTRUMENTS    AND    DRESSINGS    COMMONLY    EMPLOYED       577 

3  blunt  hook  retractors. 

2  sharp  hook  retractors. 

2  Gigh  saws. 

1  chain  saw  and  carrier. 

1  butcher  saw. 

1  metacarpal  saw. 

1  bone-cutting  forceps. 

1  rongeur  forceps. 

2  sharp  Volkmann  spoons. 

1  lion-jaw  forceps. 

2  medium-sized,   half-curved,    cutting-edge   needles    (threaded   with 

silkworm  gut). 
6  stick  sponge  holders. 
50  stick  sponges. 
30  hand  sponges. 

1  three-inch  zinc  oxid  gauze  strip. 
6  gauze  compresses. 

3  packets  of  nonabsorbent  cotton. 
3  muslin  bandages. 

Splints  (Richardson's  in  shoulder  cases,  right-angled  in  elbow  cases, 
basswood  in  wrist  cases,   Volkmann  in  knee  and  ankle  cases). 
Plaster-of-Paris  bandages,  salt  solution,  and  additional  plaster. 

LXXVI.  Amputations. 

1  large  sheet. 

2  small  protectors. 
Foot  or  hand  bags. 
1  rubber  bandage. 

1  Esmarch  constrictor. 

Wyeth's  pins,  corks,  and  three-foot-length  of  rubber  tubing  in  hip 
and  shoulder  cases. 

2  scalpels. 

2  pairs  anatomic  forceps. 

24  Kocher  clamps. 

2  blunt-nosed  clamps  (for  artery  and  vein). 

1  large  amputating  knife. 

1  Catlin  knife  (for  leg  and  forearm). 

1  pair  curved-on-the-flat,  blunt-pointed  scissors. 

1  periosteal  elevator. 

2  Gigh  saws. 
1  chain  saw. 

1  butcher  saw. 

1  mallet  and  chisel. 

1  bone-cutting  forceps. 

1  rongeur  forceps. 

1  bone-grasping  forceps. 

3  blunt  hook  retractors. 

1  bandage  retractor  (two-tailed  for  arm  and  thigh,  three-tailed  for 

forearm  and  leg). 
37 


578  OPERATING    ROOM    AXD    THE    PATIENT 

2  medium-sized,   half-curved,   cutting-edge  needles   (threaded   with 

catgut  loop  sutures). 
10  medium-sized,  half-curved,  cutting-edge  needles   (threaded  with 

silkworm  gut). 
30  hand  sponges. 
1  four-inch  zinc  oxid  gauze  strip. 
6  gauze  compresses. 

1  six-yard  gauze  roll. 

2  adhesive-plaster  taped  straps. 

1  four-inch  gauze  bandage. 
Basswood  splints. 

2  three-inch  musUn  bandages. 

LXXVn.  Suturing  of  the  PateUa. 

2  large  protectors. 

1  foot  and  leg  bag. 
6  towels. 

2  scalpels. 

2  pairs  anatomic  forceps. 
12  Kocher  clamps. 

1  pair  curved-on-the-flat,  blunt-pointed  scissors. 

2  blunt  hook  retractors. 
2  sharp  hook  retractors. 

1  sharp  Volkmann  spoon. 

1  bone  drill  (silkworm  gut  for  carrier). 

4  medium-sized,  full-curved,  cutting-edge  needles  (threaded  with 
kangaroo  tendon  or  chromic  gut,  for  lateral  sutures). 

medium-sized,  half-ciirved,  cutting-edge  needles  (threaded  with 
kangaroo  tendon  or  chromic  gut,  for  capsule  sutures  ). 

2  strands  of  kangaroo  tendon,  chromic  gut,  or  silver  wire  (for  through- 

and-through  suture). 
1  long,  straight,  spear-pointed  needle  (threaded  with  silk  for  subcu- 
ticular suture). 

1  Volkmann  splint. 

2  gauze  compresses. 

1  six-yard  gauze  roll. 

3  packets  of  nonabsorbent  cotton. 

2  three-inch  muslin  bandages  (for  foot  and  leg). 

1  four-inch  mushn  bandage  (for  thigh). 

LXXVm,  Varicose  Veins  (method  of  Trendelenburg). 

2  large  protectors. 

6  towels.  ; 

2  scalpels. 

2  pairs  anatomic  forceps. 

6  Kocher  clamps. 

2  blunt  hook  retractors. 

1  aneurysm  needle  (threaded  with  two  strands  of  catgut). 

1  pair  curved-on-the-flat,  blunt-pointed  scissors. 


INSTRUMENTS    AND    DRESSINGS    COMMONLY    EMPLOYED       579 

1  long,  straight,  spear-pointed  needle  (threaded  with  silk,  for  sub- 

cuticular suture). 
6  hand  sponges. 

2  gauze  compresses. 

2  adhesive-plaster  taped  straps. 

2  two-inch  muslin  bandages  (for  foot  and  leg) . 

2  three-inch  mushn  bandages  (for  thigh  and  pelvis). 

LXXIX.  Abscess. 

1  exploring  syringe  and  large  needle. 

1  scalpel. 

1  narrow-bladed  artery  clamp. 

6  Kocher  clamps. 

1  grooved  director. 

2  pairs  anatomic  forceps. 
2  blunt  hook  retractors. 

1  pair  curved-on-the-fiat,  blunt-pointed  scissors. 

2  sharp  Volkmann  spoons. 

6  medium-sized,  half-curved,  cutting-edge  needles   (threaded  with 

silkworm  gut). 
Peroxid  of  hydrogen. 

1  large  glass  syringe. 
Boro-salicyhc  irrigation. 
6  stick  sponge  holders. 
30  stick  sponges. 

30  hand  sponges. 

Carbolic  acid  (in  tuberculous  cases). 
Alcohol  (in  tuberculous  cases). 

Peroxided  zinc  gauze  strips  (oxid  of  zinc  gauze  strips  wrung  out  of 
peroxid  of  hydrogen). 

2  fenestrated  rubber  drainage  tubes. 
6  compresses. 

3  three-inch  gauze  bandages. 
In  Bone  Cases  (in  addition  to  above). 

1  periosteal  elevator. 

1  sequestrum  forceps. 

1  rongeur  forceps. 

3  bone  gouges. 

3  chisels. 

1  mallet. 

Mixture  of  whale  oil  and  iodoform  (for  filling  bone  cavities). 

LXXX.  Skin-grafting. 

1  skin-grafting  razor. 

1  pair  sharp  hook  retractors  (to  steady  skin). 

2  pairs  anatomic  forceps. 
2  flat-ended  silver  probes. 
Basin  of  sahne,  105°  F. 

Green-silk  i3rotective  (cut  in  one-inch  strips). 


580  OPERATING    ROOM    AND    THE    PATIENT 

6  hand  sponges. 
4  compresses  (wet  with  saUne). 
2  three-inch  gauze  bandages. 
For  Surface  to  he  Grafted  (in  addition  to  above). 

1  pair  curved-on-the-flat,  blunt-pointed  scissors. 
1  pair  straight,  sharp-pointed  scissors. 
1  Volkmann  spoon. 

LXXXI.  Plaster-of -Paris  Outfit  (apphcation  of  cast). 

VaseHn. 

Xonabsorbent  or  French  cotton  rolls. 

Canton  flannel  bandages. 

Plaster  bandages. 

Additional  plaster. 

Salt  solution  in  basin  (deep  enough  to  allow  immersion  of  bandages). 

Sandbags. 

Vinegar  (for  removing  plaster  from  the  hands). 

Adhesive  plaster  and  sharp  plaster  knife  (if  cast  is  to  be  fenestrated 
or  cut  down  at  once  to  facilitate  rapid  removal). 

Soft-iron  strips  and  bass  wood  splints  (for  strengthening  casts). 
Removal  of  Cast. 

Small  circular  saw. 

Heavy  plaster  shears. 

Heavy  plaster  knife. 

Vinegar  or  strong  bichlorid  solution  (to  soften  plaster). 

LXXXn.  Intravenous  Infusion. 

1  muslin  bandage  (for  constriction). 

1  scalpel.  *■ 

2  pairs  anatomic  forceps. 

1  aneurysm  needle  (threaded  ^^•ith  silk). 

2  Kocher  clamps. 

1  pair  curved-on-the-flat,  blunt-pointed  scissors. 

1  pair  slender,  curved-on-the-flat,  sharp-pointed  scissors. 

Infusion  cannula  and  connecting  tubing  with  cut-off. 

Glass  infusion  jar  and  thermometer. 

Stand  for  infusion  apparatus. 

Saline  solution,  120°  F.,  1200  c.c. 

1  medium-sized,    half-curved,    cutting-edge   needle    (threaded    with 

silk). 

2  hand  sponges. 

1  gauze  compress. 

1  three-inch  gauze  bandage. 

LXXXm.  Transfusion. 

2  scalpels,  one  with  small  blade. 

2  pairs  anatomic  forceps. 
1  pair  blunt  scissors. 

3  mosquito  clamps. 


INSTRUMENTS    AND    DRESSINGS    COMMONLY    EMPLOYED       581 

2  pairs  tissue  forceps  (fine). 

1  pair  curved  sharp-jDointed  scissors  (fine). 

2  Crile  clamps. 

3  single  tenaculse  (very  fine). 

1  set  Crile  cannulse,  Elsberg's  cannula,  or  Brewer's  tubes. 

1  needle  holder  (fine). 

6  very  fine   (No.  16)   cambric  needles  threaded  with  vaselined  silk. 

Rubber  tubing  to  fit  Crile  clamps. 

Saline. 

12  hand  sponges. 

2  medium-sized,  half-curved,   cutting-edge  needles    (threaded    with 

silk). 
2  three-inch  gauze  bandages. 


INDEX 


Abdomen,  cysts  of,  instruments  for, 
565 
operation  for,   after-treatment, 
484 
operations  on,  after-treatment,  442 
bowels  after,  444 
complications  after,  446 
diet  after,  444 
distention     due     to     intestinal 

atony  after,  450 
hematemesis  after,  449 
iliac  phlebitis  with  thrombosis 

after,  449 
in  pregnancy,    after-treatment, 

540 
infection  of  wound,  447 
instruments  for,  559 
intestinal  paresis  after,  451 
oozing  from   peritoneum  after, 

450 
pain  after,  445 
peritonitis  after,  446,  447 
rupture  of  wound  after,  448 
suppurative  hepatitis  after,  449 
thrombosis  after,  449 
ventral  hernia  after,  448 
preparation  of,  171 
upper,  operations  on,  position  for, 
179 
posture  after,  446 
Abdominal  binder,  115 

in  dorsal  position,  190 
distention,    facial    expression    in, 

196 
hysterectomy,     after-treatment, 

487 
paracentesis,  455 
roller  bandage,  dimensions,   67 
T-bandage,  115 

viscera,  suspension  operations  on, 
after-treatment,  462 
Abortion,  incomplete,  curettage  in, 
after-treatment,  528 
induction  of,  after-treatment,  539 
tubal,   operation   for,   after-treat- 
ment, 488 
Abscess,  instruments  for,  579 
brain,  361 

operation  for,    after-treatment, 
355 
breast,    operation  in,    after-treat- 
ment, 429 


Abscess,  peritonsillar,   operation  in, 
after-treatment,  377 
prostatic,     operation    for,     after- 
treatment,  514 
retropharyngeal,     operation     i  n, 

after-treatment,  377 
stitch,  234 

as  cause  of  postoperative  rise  of 

temperature,  222 
treatment  of,  234 
subpectoral,    operation   in,   after- 
treatment,  430 
Absorbent  cotton,  48 
Acapnia,    relation    of,    to    surgical 

shock,  161 
Acid,  bichlorid,  42 
boric,  41 
gauze  of,  45 
solution  of,  42 
carbolic,  as  antiseptic,  285 

poisoning  from,  treatment,' 286  ] 
solution  of,  42 
oxalic,  crystals: 'of ,  40 

solution  of,  42 
picric,  poisoning  from,  289 
salicylic,  rash  from,  291 
Acidosis,  postoperative,  224 
Actinomycosis  of  neck,  397 
Adenectomy,  324 

cervical,  instruments  for,  557 
for  tuberculosis,  324 
Adenoids,    removal    of,    after-treat- 
ment, 375 
instruments  for,  557 
Adenoma  of  thyroid,  enucleation  of, 

after-treatment,  418 
Adhesive  plaster,  58 

abdominal  scultetus,  61 
method  of  removal,  61 
After-treatment,  acidosis  in,  224 
albuminuria  in,  213 
anuria  in,  213 
artificial  feeding  in,  199 
aseptic  fever  in,  221 
backache  in,  198 
bed  in,  191 
catheterization  in  female  in,  214 

in  male  in,  214-218 
colonic  irrigations  in,  203,  205 
constipation  in,  202 
cupping  in,  219 
cystitis  in,  213 


583 


584 


IXDEX 


After-treatment,    delirium   tremens 
in,  222 

diet  in,  198 

digestion  in,  202 

dilatation  of    stomach    and    duo- 
denum in,  210 

distention  in,  203 

elevated  head  and  trunk  position 
in,  193 

enema  in,  203 
high,  203 
low,  204 

fecal  impaction  in,  203 

feeding  in,  198 

gavage  in,  199 

general  appearance  of  patient,  196 
considerations,  190 
rules  of  hygiene  in,  213 

hiccough  in,  209 

hydremia  in,  220 

intestinal  toxemia  in,  203 

lavage  in,  200 

length  of  stay  in  bed,  194 

nasal  feeding  in,  200 

nutrient  enema  in,  201 

pain  in,  197 

parotitis  in,  196 
treatment  of,  197 

passage  of  sounds  in,  217 

pneumonia  in,  218 

position  of  patient  in,  191 

preparation  of  bed  in,  191 

proctoclysis  in,  206 

pulse  in,  222 

purpose  of,  191 

rectal  feeding  in,  201 

respiration  in,  222  _ 

retention  of  urine  in,  213 

singultus  in,  209 

sterile  feeding  in,  202 

sterihzation  of  utensils,  191 

stomach-tube  in,  199 

subcutaneous  feeding  in,  202 

temperature  in,  220 

thirst  in,  198 

toxemia  in,  224 

urine  in,  213 
Air  embolism,  301 

Albuminuria  in  after-treatment,  213 
Alcohol,  43 

method  of  sterilization  of  catgut, 
•52 
Alexander's   operation  for   shorten- 
ing round  Ugaments,  after-  treat- 
ment, 488 
Alveolar  process,  resection  of,  after- 
treatment,  383 
Ammonia  solution,  42 
Amputations,     after-treatment     of, 
342 
arteriosclerotic  conditions,  347 
bandaging  stump,  345 


Amputations,  care  of  wound,  343 

cases  of  primary  suturing,  345 

cicatrix,  344 

drainage,  343 

gangrene,  347 

general  rules,  342  , 

infection,  343 

necrosis  of  bone,  344 
of  flaps,  343 

osteomyelitis  in,  347 

painful  conditions  of  stump,  344 

pneumonia,  347 

prosthesis,  348 

septic  conditions,  347 

shock,  343,  346 

stay  in  bed,  342 

stump  dressing  in,  343 

traumatic  cases,  345 
at  hip-joint,  after-treatment,  347 
at  thigh,  after-treatment,  348 
instruments  for,  577 
Lisfranc's,  after-treatment  of,  339 
of  breast,  after-treatment,  429 

instruments  for,  558 

position  for,  179 
of  cervix  uteri,  after-treatment,  531 
of  penis,  after-treatment,  523 
of  toes,  after-treatment,  348 
of  tongue,  after-treatment,  382 

edema  of  glottis  after,  382 

speech  after,  382 
of    upper    extremity,    after-treat- 
ment, 347 
Analgesia,  spinal,  153 

rules  for  making  injection,  154 
Anastomosis  of  nerves,  324 

for  facial  paralysis,  course  fol- 
lowing, 325 
Anesthesia,  135 

artificial  respiration  in,  158 
chloroform,  141,  147  _ 

circulatory  failure  in,  147 

respiratory  paralj^sis  in,  147 
cocain,  156 

of  skin,  157 
ether,  141 

cardiac  dilatation  in,  145 

circulatory  failure  in,  145 

compUcations  in,  143 

cyanosis  in,  143 

drop  method,  141 

respiratory  paralysis  in,  144 
ether-vapor,  145 

apparatus  for,  146 
in  thyroidectomy,  138 
insufflation,  tracheal,  150 

technic  of,  151 
local,  141,  156 
nitrous  oxid,  148 

and  ether,  149 
novocain,  157 
position  of  patient,  138 


INDEX 


585 


Anesthesia,  preliminary  medication, 
139 
preparation  just  prior  to,  175 
of  patient,  136 
special,  138 
0      recovery  from,  195 

tracheal  insufflation,  150 

technic  of,  151 
vomiting  after,  prevention,  137 
Anesthetic  nurse,  27 
room,  135 

furniture  of,  135 
selection  of,  141 
tray,  135 
vomiting,  195 

character  of  vomit,  195 
persistent,  195 
treatment,  195 
Anesthetist,  costume  of,  23 

duties  of,  140 
Aneurysm,    Matas'    operation    for, 
care  after,  322 
operations  for,  complications  after, 
321,322 
Angina,  Ludwig's,  treatment  of,  397 
Ankle-joint,     resection     of,     after- 
treatment,  337 
result,  337 
Ankylosis    of    hip,    after-treatment 

of  operations  for,  333 
Anoci-association,  163 
Antimeningitis  serum,  250 
Antiseptics,    bichlorid    of    mercury, 
287  _. 
carboUc  acid,  285 
compUcations  result  of,  282 
individual  idiosyncrasy  to,  285 
local   effect,    on   wound   surfaces, 

283 
toxicity  of,  284 

wound  disturbances  from,  282 
Antitoxin,  250 
tetanus,  250 
Antrum    of    Highmore,    opening  of, 

after-treatment,  373 
Anuria  after  operations  on  urinary 
apparatus,  498 
treatment,  500 
facial  expression  in,  196 
in  after-treatment,  213 
Anus    and   rectum,    operations    on, 
after-treatment,  489 
instruments  for,  575 
artificial,  after-treatment  of,  465 

inabihty  to  functionate,  468 
preparation  of,  173 
protectors,  37 
sterilization,  37 
Appendectomy,  instruments  for,  561 
Appendicitis,    operation    for,    after- 
treatment,  462 
complications  after,  464 


Appendicitis  with  peritonitis,  opera- 
tion for,  after-treatment,  462,  463 
Appendicostomy,  operation  for  pur- 
pose of  intestinal  irrigation  in,  464 
Aprons,  rubber,  34 
Arm,  preparation  of,  171 

reversed  spiral  bandage,  87 
Arm-sling,  111 
Arnold's  sterilizer,  39 
Arteries,  ligation  of,  effect,  319 
Artery,  carotid,  ligation  of,  compli- 
cations after,  394 
Arthrotomy     for     detached     semi- 
lunar cartilage,  336 
for    joint    mice,    after-treatment, 
336 
Articulator,  384 

Artificial  anus,  after-treatment,  465 
inabihty  to  functionate,  468 
feeding,  postoperative,  199 
larynx,  409 

Gussenbauer's,    Park's    modifi- 
cation, 411 
respiration,  158 

Laborde's  method,  160 
Sylvester's  method,  159 
Asch's  sphnt,  371 
Aseptic  fever,  230 

intestinal    fermentation    from, 

231 
postoperative,  221 
wounds,  225 

drainage  in,  228 
heaUng  by  second  intention,  229 
in  infected  tissues,  238 
Assistant's  costume,  24 
Astragalotarsal     joint,     contracture 

at,  apparatus  for  correcting,  338 
Atropin,  rash  from,  291 
Autotransfusion,  266 
AxiUa,  preparation  of,  171 

Bacillus  pyocyaneus    infection    of 

wounds,  279 
Backache,  postoperative,  198 
Bacteria,     growth     of,      action     of 

hexamethylenamin  on,   170 
Bainbridge's    method    of    preparing 

cocain  solutions,   157 
Balsam  of  Peru,  44 

gauze,  46 
Bandage,  63 

Barton's,  74 
modified,  74 

breast,  double,  97 
single,  96 

caoutchouc,  131 

Chetwood's,  for  epididymitis,' 521 

circular,  69 

classification,  63 

compound,  63 

compound.  111 


586 


INDEX 


Bandage,  crinoline,  67 
crossed,  of  head,  76 
demi-gauntlet  dorsal,  88 

palmar,  89 
Desault,  85 
dimensions,  66 
Esmarch,  69,  132 

application  of,  132 
e^'e,  for  both  eyes,  80 

single,  79 
figm-e-of-8,  72 

anterior,  of  chest,  93 

long,  of  leg,  72,  106 

of  elbow,  86 

of  foot  and  ankle,  106 

of  hand  and  wTist,  dorsal,  88 
palmar,  88 

of  knee,  103 

of  both  knees,  104 

of  neck  and  axilla,  80 

posterior,  of  chest,  94 

short,  of  leg,  72,  105 
finger,  67 
fixation,  120 
flannel,  67 
forehead  and  chin,  77 

and  neck,  78 

and  upper  Up,  77 
four-tailed,  117 
fronto-occipital,  72 
gauntlet,  89 

general  rules  in  appHcation,  67 
Gibson's,  75 
head,  72 

crossed,  76 

obhque,  72 

recurrent,  73 
hernia,  115 
immobilizing,  63 
India-rubber,  Martin's,  132 

appHcation  of,  134 
jaw,  obhque,  78 
magnesite,  131 
manufacture  of,  63 
many-tailed,  63 
materials  used,  63 
mushn,  67 
neck,  combined,  81 
obhque,  of  head,  72 

of  jaw,  78 
occipito-facial,  77 
plaster,  67 
plaster-of-Paris,  120 

application  of,  125 
precautions,  123 

manufacture  of,  122 

removal  of,  127 
pressure,  63,  131 
recurrent,  72 

of  foot,  109 

of  head,  73 

of  stump,  72 


Bandage,  removal  of,  68 
retractor,  118 
thi-ee-tailed,  118 
two-tailed,  118 
roller,  63 

abdominal,  dimensions  of,  67 
chest,  dimensions  of,  67 
double,  63 

dimensions  of,  67 
general  rules  in  application,  67 
varieties  of,  68 
rubber,    52 

sterilization  of,  52 
scissors,  68 
Scultetus,  118 
serpentine,  of  foot,  107 

of  great  toe,  110 
simple,  63 
soluble-glass,  130 
spica,  71 

ascending  double,  of  groin,  101 
of  shoulder,  81 
single,  of  groin,  98 
descending  double,  of  groin,  103 
of  shoulder,  82 
single,  of  groin,  101 
of  foot,  107 
of  gi-eat  toe,  110 
of  thumb,  90 
spiral,  69 
of  chest,  95 
of  finger,  90,  93 
of  foot,  106 
reversed,  70 
of  finger,  93 
of  foot,  107 

of  lower  extremity,  105 
of  upper  extremity,  87 
starch,  67,  129 

application  of,  130 
T-,  112 

abdominal,  115 
double,  112 
of  chest,  113 
single,  112 
triangular,  113 
of  gi'oin,  114 
uses,  63 
Yelpeau,  83 
Bandaging,  63 

stump  in  amputation,  345 
Bang's  suprapubic  drain,  512 
Bartlett's  method  of  sterilization  of 

catgut,  55 
Barton's  bandage,  74 

modified,  74 
Basins,  hand,  disinfection  of,  20 

pus,  disinfection  of,  20 
Basket  strapping  dressing  for  skin- 
grafting,  308 
for  varicose  ulcers,  241 
Bavarian  splint,  121 


INDEX 


587 


Beck's  bismuth  paste,  254 

causes  of  failure,  256 
contra-indications,   255 
course  of  cases  injected,  256 
dangers,  256 
technic  of  injection,  254 
toxic  effects,  256 
Bed  in  after-treatment,  191 
length  of  stay  in,  194 
preparation  of,  in  after-treatment, 
191 
Bedsores,    297 

treatment  of,  298 
Beebe's    nucleo-proteid    in    tetany, 

420 
Bellocq's  cannula,  369 
Benzin,  43 
Bernay's  plugs,  370 
Bichlorid,  acid,  42 
of  mercury,  41 
as  antiseptic,  287 
gauze,  46 
rash  from,  291 
Bichlorid-permanganate  solution,  42 
Bichromate  of  potash,  41 

solution,  43 
Bier's  hyperemia,  134,  251 
advantages,  251 
by   means   of   cupping   glasses, 
253,  254 
of  elastic  bandages,  251 
care  of  wound  during,  253 
duration  of  application,  253 
edema  accompanying,  253 
feelings  of  patient,  251 
Bile-ducts,     operations     on,     after- 
treatment,  476 
Binder,  abdominal,  115 
in  dorsal  position,  190 
breast,  116 
Bismuth    paste.    Beck's,    254.     See 

also  Beck's  bismuth  paste. 
Bladder,  irrigation  of,  after  catheter- 
ization, 218 
operations     on,     after-treatment, 
508 
drainage  after,  509 
infiltration  of  urine  after,  510 
puncture  of,  508 

suprapubic  drainage  of,  Dawbarn's 
apparatus  for,  512 
Blankets,  37 

sterilization  of,  38 
Block,  Volkmann's,  68 
Blood,  examination  of,  164 

transfusion   of,    direct,   266.     See 
also  Transfusion,  direct,  of  blood. 
venous,   prevention  of  return  of, 
298 
Blood-clot,  hemorrhage  from,  260 
Blood-pressure  apparatus,  166 
apphcation  of,  167 


Blood-pressure,  determining,  165 

technic  of,  165 
Boa's  nutrient  enema,  201 
Bolsters,  rubber,  52 

sterilization  of,  52 
Bone,  chisel  operations  on,  328 
disease,     tuberculous,     operation 

for,  after-treatment,  352 
necrosis  of,  in  amputation,  344 
in  injuries  of  scalp,  treatment, 
352 
operations  upon,  328 
syphilitic  necrosis,   operation  for, 

after-treatment,  352 
tumors  of,  benign,  328 
wax,  Horsley,  44 
Bony  defects,  wound  healing  in,  358 
Boric  acid,  41 
gauze,  45 
solution,  42 
Boro-saUcyhc  solution,  42 
Bougies,  filiform,  51 

steriUzation  of,  51 
Bowels,  care  of,  after  operations  on 
abdomen,  444 
preparation  of,  168 
Bow-legs,    osteotomy    of    tibia    for, 

after-treatment,  349 
Brachial     plexus,     injuries     to,     in 
operations  on  neck,  395 
suture  of,  treatment  after,  326 
Braided  catgut,  sterilization,  54 
Brain,  abscess  of,  361 

operation  for,   after-treatment, 
355 
congestion  of,  356 
edema  of,  after  removal  of  tumor, 

356 
hemorrhagic  granuloma  of,  358 
tumor    of,    operation    for,    after- 
treatment,  355 
cerebral  softening  after,  356 
edema  after,  356 
Breast,    abscess    of,    operation    in, 
after-treatment,  429 
amputation    of,    after-treatment, 
429 
instruments  for,  558 
position  for,  177 
bandage,  doub  e,  97 

single,  96 
binder,  116 

carcinoma  of,  instruments  for,  558 
operation  for,    after-treatment, 
424.     See    also  Carcinoma  of 
breast. 
resection  of,  after-treatment,  429 
Brewer's  method  of    direct   transfu- 
sion of  blood,  269 
tubes,  269 
Broad  ligament,  hematocele  of,  in- 
testinal obstruction  from,  454 


588 


IXDEX 


Bronchitis  as  cause  of  postoperative 
rise  of  temperature,  221 

Bronchopneumonia  after  operations 
on  mouth,  373 

Brushes,  sterihzation  of,  33 

Bryant's  method  of  aspiration  com- 
bined with  drainage  in  thoracic 
empj'ema,  437 

Burrell's  brass  wire  collar,  546 

Cachexia  strumipriva    after    oper- 
ations on  thyroid  gland,  420 
Calcium  salts  in  tetany,  420 
Cannula,  BeUocq's,  369 
Crile's,  268 
Elsberg's  270 
Trendelenburg,  150 
Caoutchouc  bandages,  131 
Cap,  nurse's,  35 
patient's,  35 
surgeon's,  35 
Caps,  34 

Carbohc  acid  as  antiseptic,  285 
poisoning  from,  treatment,  286 
solution,  42 
Carbohzed  gauze,  46 
Carbonate  of  soda,  41 
Carcinoma  of    breasts,    instruments 
for,  558 
operation  for,   after-treatment, 
424 
binder  after,  425 
complications,  425 
contraction  of  cicatrix,  427 
disturbance  of  drainage  after, 

426 
edema  after,  426,  428 
general  care  of  patient,  427 
keloid  after,  429 
mastitis  after,  426 
recurrence  after,  429 
redressing  after,  426 
tonsillectomy  for,  after-treatment, 
377 
Cardiac    dilatation    in    ether    anes- 
thesia, 145 
Caries   complicating   mastoid   oper- 
ations, treatment,  361 
Treves'  operation  for,  after-treat- 
ment, 544 
Carotid   artery,   ligation,    complica- 
tions after,  394 
Carotids,  occlusion  of,   instruments 

for,  558 
Cartilage,  semilunar,  detached,   ar- 
throtomy     for,      after-treatment, 
336 
Caruncle,  urethral,  excision  of,  after- 
treatment,  535 
instruments  for,  569 
Castration  in  hj'drocele,  after-treat- 
ment, 527 


Catgut,  braided,  sterilization  of,  54 
chi'omic,  Xo.  1,  sterihzation  of,  54 

No.  2,  sterihzation  of,  54 
sterihzation  of,  52 
alcohol  method,  52 
Bartlett's  method,  55 
Catheter,  flexible,  passage  of,  218 

gum-elastic,  passage  of,  218 
Catheterization,    bladder    irrigation 
after,  218 
in  female,  214 
in  male,  214-218 
Cavities,  irrigation  of,  239 
Cecostomy,  valvular,  intestinal  irri- 
gation by  means  of,  465 
Cehohysterectomy,    after-treatment 

of,  541,  542 
Cellular   infiltration,    diffuse,  treat- 
ment of,  237 
tissues,  loose,  infection  in,  238 
CeUuUtis  from  wound  infections,  272 
Cerebral  compression,  operations  for, 

after-treatment,  354,  355 
Cerebral  hernia,  357 
prolapse,  357 

softening  after  removal  of  brain 
tumor,  356 
Cerebrospinal  fluid,  escape  of,  357 
meningitis,    antimeningitis  serum 
in,  250 
Cerebro-topographic  hues  of  Kron- 

lein,  169 
Cervical    adenectomj^,    instruments 
for,  557 
spondj^htis,    operation  for,    after- 
treatment,  544 
Cervix  uteri,   amputation  of,   after- 
treatment,  531 
laceration  of,  suture,  after-treat- 
ment, 530 
operations     on,     complications, 

531 
section  of,  by  multiple  incisions, 
after-treatment,  540 
Cesarean  section,  after-treatment  of, 
541 
instruments  for,  565 
vaginal,  after-treatment  of,  540 
Cheek,  plastic  operations  on,  after- 
treatment,  366 
Chest,  anterior  figure-of-8  bandage, 
93 
posterior  figure-of-8  bandage,    94 
roller  bandage,  dimensions,  67 
spiral  bandage,  95 
T-bandage,  113 
Chetwood's    bandage    for    epididy- 
mitis, 521 
Chiene's  device  for  locating  fissure  of 

Rolando,  170 
Chisel  operations  on  bone,  328 
Chlorid  of  zinc  solution,  43 


INDEX 


589 


Chlorinated  lime,  34 
Chloroform  anesthesia,  141,  147 
circulatory  failure  in,  147 
respiratory  paralysis  in,  147 
Cholecystectomy,  a  f  t  e  r-treatment, 
481 

instruments  for,  564 
Cholecystenterostomy,     after-treat- 
ment, 481 

instruments  for,  565 
Cholecystostomy,     after-treatment, 
477 

biUary  fistula  after,  480 

blockage  of  tube  in,  479 

in  jaundiced  patients,  480 

instruments  for,  564 

primary  dressing  after,  479 
Cholecystotomy,     after-treatment, 

480 
Choledochostomy,    after-treatment, 

481 
Choledochotomy,  after-treatment, 

481 
Christy  knife  for  cutting  bandages, 

66 
Chromic  catgut  No.  1,  sterilization, 
54 

No.  2,  sterilization,  54 
Cicatricial  contractures,  318 
Cicatrix,  304 

in  amputation,  344 

invisible,  304 
Cicatrization,  304 
Cigarette  drain,  modified,  47 
Circular  bandage,  69 
Circulation,    disturbances   of,    com- 
plicating  operations   on   vascular 

system,  319 
Circulatory  complications  of  wounds 
298 

failure  in  chloroform     anesthesia, 
147 
in  ether  anesthesia,  145 
Circumcision,     after-treatment     of, 
522 

edema  after,  523 

hemorrhage  after,  523 

instruments  for,  570 
Clamp,  Crile's,  268 

Dupuytren's,  467 
Clavicle,  fracture,  Desault  bandage 

in,  86 
Cleft  palate  operation,  preparation 

for,  172 
Clubfoot,  Sayre's  shoe  for,  338 
Cocain  anesthesia,  156 
of  skin,  157 

hydrochlorate,  41 

solutions,  44 
Cohen's  tracheotomy  tubes,  400 
Colitis,    operation    for    purpose    of 

intestinal  irrigation  in,  464 


Collodion,  44 

Colon    bacillus    infections,    vaccine 
therapy,  250 

chronic     inflammatory     diseases, 
operations  for  intestinal  irriga- 
tion in,  464 
Colonic    irrigations    in    after-treat- 
ment, 203,  205 
Colostomy,     inguinal,     instruments 

for,  562 
Colporrhaphy,   anterior,  after-treat- 
ment of,  531 

instruments  for,  568 
Colpotomy,  instruments  for,  568 

posterior,  after-treatment  of,  535 
complications  of,  536 
Commercial  ether,  43 
Compress,  plaster-of-Paris,  120 
Compresses,  49 
Compression,     cerebral,     operations 

for,  after-treatment,  354,  355 
Concealed  hemorrhage,  259 
Congestion  of  brain,  356 
Conjunctivitis   in    wounds   of   face, 

treatment,  364 
Constipation      in      after-treatment, 

202 
Constriction  paralysis,  294 
Contractures  at   astragalotarsal 
joint,  apparatus  for  correcting, 
_338_  _ 

cicatricial,  318 

Dupuytren's,  317 

habitual,  318 

ischemic  muscular,  296 

of  finger-joints,  318 

of  hip,  after-treatment  of  opera- 
tions for,  333 
Copaiba,  rash  from,  291 
Corsets,   poroplastic  felt,  in  tuber- 
culous spondylitis,  549 
Cotton,  absorbent,  48 

nonabsorbent,  48 
Covers  for  rubber  pads,  38 
Craniectomy,  instruments  for,  554 
Crile's  cannula,  268 

clamp,  268 

method   of   direct   transfusion   of 
blood,  267 
Crinoline  bandage,  67 
Crossed  bandage  of  head,  76 
Cupping,  postoperative,  219 
Curettage,  after-treatment  of,  527 

complications  of,  529 

instruments  for,  567 
Curette,  Delatour's  sinus,  244 
Cut  throat,  instruments  for,  558 
Cyanosis  in  ether  anesthesia,  143 
Cystitis  after  lithotrity,  prevention, 
513 

after  perineal  cystotomy,  519 

in  after-treatment,  213 


590 


IXDEX 


C3'stotoniy,     perineal,     after-treat- 
ment of,  514: 
care  of  wound,  519 
cystitis  after,  519 
diet  after,  517 
perineal  fistula  after,  519 
suprapubic,   instruments  for,   573 
with  temporary  drainage,  after- 
treatment,  511 
without    drainage,    after-treat- 
ment, 511 
Cvsts,    echinococcus,   treatment  of, 
"     485  _ 

of  abdomen,  instruments  for,  565 
operation   for,    after-treatment, 
484 
of  thjToid,  enucleation  of,  after- 
treatment,  418 

Dam,  rubber,  sterilization  of,  51 
Dawbarn's     apparatus     for     supra- 
pubic di'ainage  of  bladder,  512 
Death,  sudden  following  operation, 

cause  of,  303 
Decortication    of    lung,    after-treat- 
ment, 439 
Decubitus,  297 

treatment  of,  298 
Degeneration,  malignant,  in  scar  tis- 
sue, 312 
Delatom''s  sinus  cui-ette,  244 
Delirium     tremens,     postoperative, 
222 
symptoms  of,  223 
treatment  of,  223 
Demi-gauntlet  bandage,  dorsal,  88 

palmar,  89 
Dependent  head  position,  175 
Dermatitis     comphcating     mastoid 

operations,  treatment,  361 
Desault  bandage,  85 
Deviated  septum,   instruments  for, 

557 
Didot's  operation,  312 
Diet,  168 

after  operations  on  abdomen,  444 
on  rectum  and  anus,  497 
perineal  cystotomy,  514 
postoperative,  198 
Diffuse    cellular    infiltration,    treat- 
ment, 237 
Digestion  in  after-treatment,  202 
Dilatation  aft  er  tracheotomy,  406 
cardiac,  in  ether  anesthesia,  145 
of  stomach  and  duodenum,  post- 
operative, 210 
treatment,  212 
Diphtheria,  wound,  in  tracheotomv, 

405 
Disarticulations,  after-treatment  of, 
342 
care  of  wound,  343 


Disarticulations,  after-treatment  of, 
general  rules,  342 
stay  in  bed,  342 
Disinfection  of  dressing  pails,  20 
of  glassware,  20 
of  hand  basins,  20 
of  hands,  187 
of  operating  room,  18 
of  pitchers,  20 
of  pus  basins,  20 
Dislocation,    fracture,    of   vertebrae, 
operations  for,   after-treatment, 
542 
of  jaw,  after-treatment,  386 
Distention,  abdominal,  facial  expres- 
sion in,  196 
due  to  intestinal  atony  after  opera- 
tions on  abdomen,  450 
in  after-treatment,  203 
Diverticula  of  esophagus,  172 

excision  of,  after-treatment,  414 
Dorsal  position,  180 

abdominal  binder  appUed,  190 
operation  suit,  174 
ready  for  final  preparation,  186 
for  operation,  187 
Drainage  after  herniotomy,  469 
after  operations  on  bladder,  509 
blocking  of,  retention  of  secretion 

in  wound  bj-,  239 
cases,  articles  required,  560 
in  amputations,  343 
in  aseptic  wounds,  228 
in  operations  on  uterus,  487 
in  suppurative  pleuritis,  433 
in  thoracic  empyema,  433 
suprapubic,  of  bladder,  Dawbarn's 

apparatus  for,  512 
tube,  glass,  52 
rubber,  50 

sterilization  of,  50 
self-retaining,  51 
Drains,  46 

cigarette,  modified,  47 
gauze,  46 
Mikuhcz,  47 

removal  of,  239 
rubber  tissue,  47 
wicking,  46 
Dressing  materials,  sterilization,  38 
of  wounds,  primary,  226 
pails,  disinfection,  20 
paper,  50 
primary,  163 
Dressings,  553 

apphcation  of,  189 
revision  of,  of  wounds,  225 
Drop   method   of   ether   anesthesia, 

141 
Drugs,  rashes  due  to,  291 
Dudley's     operation     for     cervical. 
stenosis,  after-treatment,  531 


INDEX 


591 


Duodenum  and  stomach,  dilatation 
of,  post-opei'ative,  210 
treatment,  212 
mesenteric  incarceration  of,  post- 
operative, 210 
Dupuytren's  clamp,  467 

contracture,  317 
Dysentery,    operation    for    purpose 
of  intestinal  irrigation  in,  464 

EcHiNococcus  cysts,  treatment,  485 
Edema  after  circumcision,  523 
after  operation  for  carcinoma  of 

breast,  426,  428 
lymphatic,     after    operations    on 
lymphatic  system,  322 
from  wound  infection,  272 
malignant,  from  wound  infection, 
278 
treatment,  279 
of  brain  after  removal  of  tumor, 

356 
of  glottis  after  amputation,  382 
after  operations  on  neck,  397 
Elbow,  figure-of-8  bandage,  86 
preparation  of,  171 
splint,  332 
Elbow-joint,  resection  of,  after-treat- 
ment, 332 
Elevated  head  and  trunk  position, 

193 
Elsberg's  cannula,  270 

method   of   direct   transfusion   of 
blood,  270 
Embolism,  321 
air,  301 
fat,  300 

shock  and,  differentiation,  302 
Emphysema,  infectious,  279 

of     subcutaneous     tissues     after 
operation  for  thoracic  empyema, 
436 
Empyema,  thoracic, Bryant's  method 
of    aspiration    and    drainage 
in,  437 
drainage  in,  433 
instruments  for,  559 
operation    in,    after-treatment, 
433 
duration  of  healing,  438 
emphysema  of  subcutaneous 

tissues  after,  436 
empyema    of    opposite   side 

complicating,  436 
fever  after,  435 
fistula  after,  438 
hemorrhage  after,  436 
lung  gymnastics  after,  437 
position  of  patient  after,  435 
secondary  scoliosis  after,  438 
Endometritis,    septic,    curettage   in, 
after-treatment,  528 


Endometritis,  simple,   curettage  in, 

after-treatment,  527 
Enema,  high,  in  after-treatment,  203 
in  after-treatment,  203 
low,  in  after-treatment,  204 
nutrient.  Boas',  201 
Ewald's,  201 
in  after-treatment,  201 
Leube's,  201 
rashes  after,  291 
Enterocohtis,  operation  for  purpose 

of  intestinal  irrigation  in,  464 
Enucleation  of  eye,  after-treatment, 
365 
of  tumors  of  thyroid,  after-treat- 
ment, 418 
Epididymitis    after    perineal    pros- 
tatectomy, 522 
Chetwood's  bandage  for,  521 
Episiotomy,  after-treatment  of,  640 
Epispadias,    operations    for,    after- 
treatment,  524 
Epithelioma    of    lip,    operation    in, 

after-treatment,  367 
Erysipelas    buUosum    from    wound 
infection,  276 
complicating    wounds    of    scalp, 

352 
from  wound  infection,  276 

treatment,  277 
of  scalp,  phlegmonous  inflamma- 
tion and,  differentiation,  353 
Esmarch  bandage,  69,  132 

application,  132 
Esophagectomy,  after-treatment  of, 
414 
secondary  hemorrhage  after,  414 
sepsis  after,  414 
stricture  after,  414 
Esophagotomy,  after-treatment,  413, 

415 
Esophagus,  diverticula  of,  172 

excision  of,  after-treatment,  414 
operations     on,     after-treatment, 

413 
preparation  of,  172 
stricture  of,  after  esophagectomy, 
434 
Estlander's    thoracoplasty,     after- 
treatment,  439 
Ether  anesthesia,  141 

cardiac  dilatation  in,  145 
circulatory  failure  in,  145 
comphcations,  143 
cyanosis  in,  143 
drop  method,  141 
respiratory  paralysis  in,  144 
commercial,  43 
mask,  136 
rash,  292 
Ether-vapor  anesthesia,  145 
apparatus  for,  146 


592 


IXDEX 


Ewald's  nutrient  enema,  201 
Excision  of  esophageal  diverticula, 
after-treatment,  414 
of  trigeminus,  instruments  for,  554 
of  upper  jaw,  instruments  for,  554 
of  urethral  caruncle,   after-treat- 
ment, 535 
Exophthalmic  goiter,  operation  for, 
after-treatment,  415,  416 
preparation,  174 
Exploratory  laparotomy,  after-treat- 
ment of,  486 
Extended  neck  position,  176 
Extirpation  of  penis,  after-treatment, 
524 
of  rectum,  after-treatment,  494 
Extraction  of  teeth  after-treatment, 

383 
Exraperitoneal   section,    after-treat- 
ment, 541 
shortening    of    round    Hgaments, 
after-treatment,  488 
Extra-uterine    pregnancy,    instru- 
ments for,  561 
operation  for,    after-treatment, 
488 
Extremities,  preparation  of,  174 
Exuberant  granulation,  239,  240 
Eye,  bandage,  for  both  eyes,  80 
single,  79 
enucleation     of,     after-treatment, 

365 
protection    of,    in    operations    on 
face,  364 
Eyelids,   operations  on,   after-treat- 
ment, 364 

Face,   neurectomies  on,  superficial, 
after-treatment,  367 
operations  on,  after-treatment, 
363 
conjunctivitis  in,  364 
hemorrhage  in,  364 
protection  of  eye  in,  364 
wounds  of,  after-treatment,  363 
Facial  expression  in  abdominal  dis- 
tention, 196 
in  anuria,  196 
in  hemorrhage,  196 
in  parotitis,  196 
in  peritonitis,  196 
in  pneumonia,  196 
parah'sis,  nerve  anastomosis  for, 
course  following,  325 
trismus   with,    from  wound  in- 
fection, 281 
Fallopian   tubes,   operations   on, 

after-treatment,  488 
Fat  embohsm,  301 

shock  and,  differentiation,  302 
necrosis   after  operations  on  kid- 
nev,  507 


Fecal   fistula,    operation   for,    after- 
treatment,  468 
impaction  in  after-treatment,  203 
phlegmon,  489 
Feces,  incontinence  of,  after  opera- 
tions on  rectum  and  anus,  496 
Feeding,     artificial,     postoperative, 
199,  200 
nasal,  postoperative,  200 
postoperative,  198 
rectal,  postoperative,  201 
sterile,  postoperative,  202 
subcutaneous,   postoperative,  202 
Feet,  preparation  of,  171 

sole  of,  preparation,  171 
Female,  catheterization  in,  214 
Femoral    hernia,    instruments    for, 
566 
operation  for,    after-treatment, 
476 
vein,  hgation  of,  impending  gan- 
grene following,  321 
thrombosis  of,  299 
treatment,  300 
Femur,  neck  of,  impacted  fracture, 

after-treatment  of,  340 
Fermentation,  intestinal,   aseptic 

fever  from,  231 
Figure-of-8  bandage,  72 
anterior,  of  chest,  93 
long,  of  leg,  72,  106 
of  elbow,  86 
of  foot  and  ankle,  106 
of  hand  and  wrist,  dorsal,  88 

palmar,  88 
of  knee,  103 

of  both  knees,  104 
of  neck  and  axilla,  80 
posterior,  of  chest,  94 
short,  of  leg,  72,  105 
Files,  nail,  34 
Fihform  bougies,  51 
sterilization,  51 
Finger  bandage,  67 
cots,  37 

spu-al  bandage,  90,  93 
reversed,  93 
Finger-joints,  contracture  of,  318 
Fissure  of  Rolando,  location,  169 

of  Sylvius,  169 
Fistula  after  excision  in  suppurative 
adenitis,  324 
after  operation  in  thoracic  empy- 
ema, 438 
fecal,    operation    for,    after-treat- 
ment, 468 
instruments  for,  570 
of  pancreas  after  operations,  483 
parotid,  after  operation,   366 
perineal,  after  perineal  cystotomy, 
519 
prostatectomy,  522 


INDEX 


593 


Fistula,  rectovaginal,  operation  for, 
after-treatment,  533 
urethral,    closure    of,    after-treat- 
ment, 523 
operation  for,   after-treatment, 
532 
urinary,  after  nephrotomy,  506 
vesicovaginal,  operation  for,  after- 
treatment,  532 
Fixation  bandages,  120 
Flail-like  joints,  331 
Flanged  glass  drainage  tubes,  52 
Flannel  bandage,  67 
Flat-foot,  194 

treatment  of,  194 

Whitman's  plate  in,  194 
Flexner's  antimeningitis  serum,  250 
Foot  and  ankle,  figure-of-8  bandage, 
106 
flat-,  194 

recurrent  bandage,  109 
serpentine  bandage,  107 
spica  bandage,  107 
spiral  bandage,  106 
reversed,  i07 
Forehead  and  chin  bandage,  77 
and  neck  bandage,  78 
and  upper  lip  bandage,  77 
Foreign  body  pneumonia,  218 
Formalin  glycerin  mixture,  43 
Four-tailed  bandage,  117 
Fowler's  decortication  of  lung,  after- 
treatment,  439 
operating  table,  19 
Fracture,  after-treatment  of,  339 
complications  of,  late,  340 
dislocation    of    vertebrae,    opera- 
tions for,  after-treatment,  542 
of  clavicle,    Desault  bandage  in, 

86 
of  femur,  of  neck,  impacted,  after- 
treatment  of,  340 
of  jaw,  after-treatment,  383 

interdental   splint  in,   384 
of  patella,  after-treatment,  341 
of  ribs,  operation  in,  after-treat- 
ment, 430 
of  skull,   compound,   without  de- 
pression, initial  treatment,  353 
of  vertebrae,  operations  for,  after 

treatment,  542 
treatment     of,     operative,     after- 
treatment,  340 
French  saw  for  removal  of  plaster- 

of-Paris  casts,  127 
French's  combined  forceps  and  re- 
tractors, 399 
Frontal   sinus,     opening    of,    after- 
treatment,  372 
operations  on,  after-treatment, 
369 
Fronto-occipital  bandage,  72 

S8 


Furniture  in  operations  in  private 
houses,  28 
of  anesthetic  room,  135 
of  operating  room,  17 

Gall-bladder,  operations  on,  after- 
treatment,  476 
Gall-stones,     operation    for,     after- 
treatment,  476 
Gangrene  in  amputation,  347 
hospital,  277 

treatment  of,  278 
impending,  following    ligation    of 

femoral  vein,  321 
of    testicle     after    operation    for 

varicocele,  treatment,  525 
pressure,  local,  297 
Gant's  method  of  intestinal  irriga- 
tion, 465 
Gastrectomy,  after-treatment,  461 

instruments  for,  563 
Gastro-enterostomy,    after-treat- 
ment, 458 
complications  after,  459 
instruments  for,  563 
vomiting  after,  459,  460 
Gastrorrhaphy,  after-treatment,  458 
Gastrostomy,    after-treatment,    455 
closure  of  fistula,  457 
instruments  for,  563 
retrograde  dilatation  of  esophagus, 
457 
Gastrotomy,   after-treatment,  457 

instruments  for,  563 
Gauntlet  bandage,  89 
Gauze,  44 

balsam  of  Peru,  46 
boric  acid,  45 
carbolized,  46 
cleaning  of,  50 
drains,  46 

removal,  239 
iodoform,  No.  1.,  44 
No.  2,  45 
No.  3,  45 
No.  4,  45 
of  bichlorid  of  mercury,  46 
sterilization  of,  38,  44 
Thiersch,  46 
zinc  oxid,  45 
Gavage  in  after-treatment,  199 
Genitals,     female,     operations     on, 
after-treatment,  527 
plastic  operations  on,  intercourse 
after,  539 
male,    operations   on,    after-treat- 
ment, 522 
Genu  valgum,  osteotomy  for,  after- 
treatment,  349 
Gibson's  bandage,  75 

method  of  suprapubic  cystotomy, 
after-treatment,  511 


594 


INDEX 


Glass  drainage  tube,  52 
goods,  52 

sterilization,  52 
Glassware,  cleansing  of,  20 
Glottis,  edema  of,  after  amputation, 
382 
after   operations  on  neck,   397 
Gloves,  rubber,  sterilization  of,  35 
Glycerin,  43 

Goiter,  exophthalmic,  operation  for, 
after-treatment,  415,  416 
preparation,  174 
Instruments  for,  558 
operations  for,  preparation,  174 
Gonococcus  vaccines,  250 
Gowns,  35 
nurses',  35 
operators',  35 
sterihzation  of,  38 
Graduated  tampon,  49 
Grafting,  skin-,  306 

basket   strapping  dressing  for, 

308 
open  treatment,  308 
Granulation,  disturbances  of,  239 
exuberant,  239,  240 
pyogenic  membrane  in,  239 
sluggish,  239 
Granuloma  after  tracheotomy,  406 

hemorrhagic,  of  brain,  358 
Great  toe,  serpentine  bandage,  110 

spica  bandage,  110 
Green  silk  protective,  51 

sterilization,  51 
Groin,  ascending  double  spica  band- 
"   age,  101 

single  spica  bandage,  98 
descending  double  spica  bandage, 
103 
single  spica  bandage,  101 
triangular  bandage,  114 
Gussenbauer's  artificial  larynx, 
Park's  modification,  411 

Habitual  contractures,  318 
Hahn's   operation   for   undescended 

testicle,  after-treatment,  525 
Hallux  valgus,  operation  for,  after- 
treatment,  348 
Hand  and  wrist,  figure-of-8  bandage, 
dorsal,  88 
palmar,  88 
basins,  disinfection,  20 
lotions,  34 
sponges,  48 
Handley's  lymphangioplasty,  323 
Hands,  after-care  of,  188 
disinfection  of,  187 
preparation  of,  171 
Harelip  operations,  after-treatment, 
367 
instruments  for,  555 


Head  and  trunk  position,  elevated, 
193 
bandages,  72 
crossed,  76 
obhque,  72 
recurrent,  73 
operations     on,     after-treatment, 
351 
general  rules  for,  359 
complications,  late,  360 
hemorrhage  in,  prevention,  170 
position,  dependent,  175 
preparation  of,  169 
Headache  in  spinal  analgesia,  154 
HeaUng  by  second  intention,  229 

wound,  in  bony  defects,  358 
Heart,  examination  of,  164 

operations     on,     after-treatment, 
440 
complications  after,  440 
hemorrhage  after,  440,  441 
pericarditis  after,  441 
shock  after,  440 
Hematemesis    after    operations    on 

abdomen,  449 
Hematocele  of  broad  ligament,  in- 
testinal obstruction  from,  454 
Hematoma  after  operations  on  scro- 
tum, 524 
of  sternomastoid  after  operations 
on  neck,  397 
Hematuria  after  operation  on  kidney, 

502 
Hemolysis  in  direct  transfusion   of 

blood,  266 
Hemophihacs,  257 
Hemorrhage,  257 

after  circumcision,  523 
after  hepatectomj',  457 
after  nephrotomy,  504 
after  operations  on  heart,  440,  441 
on  lung,  440 
on  pancreas,  482 
on  rectum   and  anus,  490 
concealed,  259 
facial  expression  in,  196 
from  blood-clot,  260 
from  infection  or  erosion,  260 
from  loosening  of  ligature,  259 
from  vascular  paresis,  260 
from  vessels  of  large .  cahber,  259 
from  wounds,   diagnosis,  260 

treatment,  261 
in  cavity  after  removal  of  tumor 

of  brain,  treatment,  355 
in  operations  on  face,  364 

on  head,  prevention,  170 
in  resection  of  one-haK  of  upper 

jaw,  389 
in  tracheotomy,  404 
intravenous     saline    infusion     in, 
263 


INDEX 


595 


Hemorrhage,      middle      meningeal, 
compression  from,  operation  for, 
after-treatment,  355 
postoperative,  257 
prevention    of,    in   operations   on 

nose,  369 
primary,  from  wounds,  258 
secondary,    after    esophagectomy, 
414 
after  operations  on  neck,  394 

on  thyroid  gland,  417 
after  splenectomy,  482 
after  splenotomy,  481 
after  tracheotomy,  404 
complicating    operations  on 

vascular  system,  319 
from  wounds,  258 
diagnosis,  260 
late,  treatment  of,  262 
treatment,  261 
in     intracranial     neurectomies, 
363 
Hemorrhagic    granuloma    of    brain, 

358 
Hemorrhoids,  instruments  for,  575 
Hepatectomy,    after-treatment,   475 

hemorrhage  after,  475 
Hepatitis,  suppurative,  after  opera- 
tions on  abdomen,  449 
Hepatopexy,  after-treatment,  476 
Hepatotomy,    after-treatment,    475 
Hernia  bandage,  115 
cerebri,  357 

femoral,  instruments  for,  566 
operation  for,    after-treatment, 
471 
incarcerated,  operation  for,  after- 
treatment,  471 
complications  after,  471 
paresis  of  affected  loop  after, 

473 
peritonitis  after,  472 
secondary   perforation   of 

affected   loop   after,   472 
stenosis  of  intestine  after,  474 
wound   treatment  after,   474 
inguinal,  instruments  for,  566 
operation  for,    after-treatment, 
468 
umbihcal,  instruments  for,  566 
operation  for,    after-treatment, 
471 
ventral,    after    operations   on  ab- 
domen, 448 
instruments  for,  566 
operation   for,    after-treatment, 
471 
Herniotomy,  after-treatment,  468 
difficulty  of  urination  after,  471 
drainage  after,  469 
hydrocele  after,  471 
necrosis  of  sac  after,  470 


Herniotomy,     necrosis    of     testicle 
after,  470 
phlebitis  of  femoral  vein  after,  471 
recurrence  after,  470 
Herpes,  postoperative,  290 
Hexamethylenamin,  action  o  f ,  on 

growth  of  bacteria,  170 
Hiccough,  postoperative,  209 
Highmore,     antrum     of,     opening, 

after-treatment,  373 
Hip,  amputation  at,  after-treatment, 
347 
contractures     and     ankylosis    of, 
after-treatment    of    operations 
for,  333 
resection     of,      for     tuberculosis, 
after-treatment,  333 
functional  results,  335 
splint,  Taylor's,  335 
Hooks,  skin-stretching,  307 
Hormonal,  451 

administration  of,  453 
indications  for  use,  453 
Hormone,  peristaltic,  451 
Horsehair,  sterilization  of,  56 
Horsley  bone  wax,  44 
Hospital  gangrene,  277 

treatment,  278 
Houses,  private,  operations  in,  27 
furniture,  28 
preparation  of  room,  28 
Hydremia,  postoperative,  220 
Hydrocele  after  herniotomy,  471 
castration  in,  after-treatment,  527 
injection   methods   of   treatment, 

527 
instruments  for,  571 
operation  for,  after-treatment   of, 
525 
securmg  cure  through  granula- 
tion, 527 
tapping  of,  525 
Hydrogen  peroxid,  43 
Hydronephrosis,  operation  for,  after- 
treatment,  507 
Hygiene,  general  rules  of,  in  after- 
treatment,  213 
Hyperemia,    Bier's,    134,    251.     See 

also  Bier's  hyperemia. 
Hypernephroma,    operation  for, 

after-treatment,  482 
Hypodermoclysis,  265 
Hypospadias,  instruments  for,  571 
operations     for,     after-treatment, 
524 
Hypostatic  pneumonia,  218,  221,  222 
Hysterectomy,      abdominal,     after- 
treatment  of,  487 
instruments  for,  562 
vaginal,  after-treatment  of,  537 
complications  of,  538 
infection  in,  539 


596 


IXDEX 


Hysterectomy,    vaginal,    injury    to 
ureter  in,  538 
instruments  for,  569 
intestinal  obstruction  in,  539 
Hysterical  paralysis,  294 
Hysterotomj',    vaginal,    anterior, 
after-treatment  of,  540 

ICHTHYOL,   44 

Ileocolostomy,  instruments  for,  562 
Iliac  phlebitis  with  thrombosis  after 

operations  on  abdomen,  449 
Impaction,  fecal,  in  after-treatment, 

203 
Incarcerated    hernia.     See    Hernia, 

incarcerated. 
Incision,     kidney,     closing,     instru- 
ments for,  574 
for   exposing,    instruments   for, 
573 
laparotomy,   instruments  for,  560 
closing,  561 
dressing,  561 
making,  560 
retracting,  560 
Incontinence  of  feces  after  operation 

on  rectum  and  anus,  496 
Index,  opsonic,  246,  247 
India-rubber      bandage,      ^Martin's, 
132 
appUcation  of,  134 
tourniquet,  132 
Indolent  wounds,  treatment,  240 
Infection,  hemorrhage  from,  260 
in  amputation,  343 
of  wounds,  230.     See  also  Wounds, 
infection  of. 
Infectious  emphysema,  279 
Infiltration,    diffuse    cellular,    treat- 
ment of,  237 
phlegmonous,  of  scalp.  352 

ervsipelas  and,  differentiation, 
353 
of  tissues  of  neck,  after  opera- 
tions on  mouth,  374 
Ingrown  toe  nail,  314 
Inguinal  colostomy',  instruments 
for,  562 
hernia,  instruments  for,  566 
operation  for,  after-treatment, 
468 
Instrument  room,  31,  32 
table,  arrangement,  21 

portable,  arrangement  of,  22 
Instruments,  30,  553 

for  abdominal  cysts,  565 

operations.  559 
for  abscess,  579 
for  adenoid  operations,  557 
for  amputation  of  breast,  558 
for  amputations,  577 
for  appendectomy,  561 


Instruments  for  carcinoma  of  breast, 

558 
for  cervical  adenectomy,  557 
for  Cesarean  section,  565 
for  cholecystectomy,  564 
for  cholecj'Stenterostomy,  565 
for  cholecystostomy,  564 
for  circumci.sion,  570 
for  colporrhaphy,  568 
for  colpotomy,  568 
for  craniectomy,  554 
for  curettage,  567 
for  cut  throat,  558 
for  deviated  septum,  557 
for  empyema,  559 
for  excision  of  trigeminus,  554 

of  upper  jaw,  554 
for  extirpation  of  rectum  by  ab- 
dominoperineal route,  576 
for  extra-uterine  pregnancy,  561 
for  femoral  hernia,  566 
for  fistula,  570 
for  gastrectomy,  563 
for  gastro-enter ostomy,  563 
for  gastrostomy,  563 
for  gastrotomy,  563 
for  goiter,  558 
for  harehp  operation,  555 
for  hemorrhoids,  575 
for  hydrocele,  571 
for  hypo.spadias,  571 
for  hysterectomy,  562 
for  ileocolostomy,  562 
for  inguinal  colostomy,  562 

hernia,  586 
for  internal  urethrotomy,  571 
for    intravenous    sahne    infusion, 

580 
for  kidney  exploration,  574 

incision,  573 
closing,  574 
exposing,  573 

suspension,  574 
for  laparotomy  incision,  560 
closing,  561 
dressing,  561 
maldng,  560 
retracting,  560 
for  nephrectomy,  574 
for  neplu'otomy,  574 
for  occlusion  of  carotids,  558 
for  oophorectomy,  561 
for  opening  mastoid,  555 
for  operations  on  anus,  575 

on  rectum,  575 

on  scalp.  553 
for  perineal  prostatectomy,  573 

section,  572 

without  a  guide  in  impassable 
strict m'e,  572 
for  perineorrhaphy,  569 
for  prolapse  of  rectum,  576 


INDEX 


597 


Instruments  for  removal  of  plaster- 
of-Paris  cast,  580 
for  resection  of  intestine,  562 
of  joints,  576 
of  lower  jaw,  555 
of  rib,  559 
for  salpingo-oophorectomy,  561 
for  skin-grafting,  579 
for  staphylorrhaphy,  556 
for  stone  cases,  572 
for  suprapubic  cystotomy,  573 
for  suture  of  patella,  578 
for  tonsillectomy,  556 
for  trachelorrhaphy,  568 
for  tracheotomy,  557 
for  transfusion,  580 
for  trephining,  554 
for  umbilical  hernia,  566 
for  uranoplasty,  556 
for  urethral  caruncle,  569 
for  vaginal  hysterectomy,  569 

operations,  567 
for  varicocele,  570 
for  varicose  veins,  578 
for  ventral  hernia,  566 
preparation  of,  30 
sterilization  of,  31 
Insufflation  anesthesia,  tracheal,  150 
technic  of,  151 
intr  alary  ngeal,  160 
Meltzer's  method,  160 
Intercourse  after  plastic  operations 

on  female  genitals,  539 
Interdental  splint,  384 
Intermuscular  phlegmon,  236 
Intestinal    fermentation,    aseptic 
fever  from,  231 
irrigation   by   means   of  valvular 
cecostomy,  465 
Gant's  method,  465 
in     chronic    inflammatory    dis- 
eases of  colon,  operations  for, 
464 
obstruction   in   vaginal   hysterec- 
tomy, 539 
postoperative,  453 

from    hematocele    of    broad 

ligament,  454 
from  peritonitis,  454 
late,  455 
paresis  after  operations  on  abdo- 
men, 451 
toxemia  in   after-treatment,   203 
Intestine,  large,  preparation  of,  173 
operations     on,     after-treatment, 

462 
resection  of,  instruments  for,  562 
small,  preparation  of,  173 
stenosis    of,    after    operation    for 
incarcerated  hernia,  474 
Intracranial  neurectomies,  362 

secondary  hemorrhage  in,  363 


Intracranial  operations,  after-treat- 
ment, general  rules  for,  359 
complications,  late,  360 
Intralaryngeal  insufflation,  160 

Meltzer's  method,  160 
Intravenous  saline  infusion,  263 
indications,  263 
instruments  for,  580 
physiologic  action,  263 
technic,  263 
without  dissection,  265 
Intubation  instruments,  O'Dwyer's, 
410 
of  larynx,  410 
dangers,  412 
removal  of  tube,  412 
technic,  411 
Invisible  cicatrix,  304 
Iodoform  emulsion,  42 
gauze  No.  1,  44 
No.  2,  45 
No.  3,  45 
No.  4,  45 
mixture,  44 
poisoning,  288 

systemic,  288 
powder,  39 
rash  from,  291 
Iron  wire,  sterihzation,  56 
Irrigation,   intestinal,   by  means  of 
valvular  cecostomy,  465 
Gant's  method,  4 
in  chronic  inflammatory  diseases 
of  colon,  operations  for,  464 
of  cavities,  239 
Ischemic  muscular  paralysis  and  con- 
tracture, 296 

Janeway's  portable  sphygmomano- 
meter, 165 
Jaw,  bandage,  obhque,  78 

dislocation     of,     after-treatment, 

386 
four-tailed  bandage,  118 
fracture  of,  after-treatment,  383 

interdental  splint  in,  384 
lower,   Barton's  bandage  for,   74 
modified,  74 
resection   and    disarticulation, 
after-treatment,  390 
prosthesis  after,  393 
suffocation  after,  392 
instruments  for,  555 
upper,  excision  of,  instruments 
for,  554 
resection     of    one-half,     after- 
treatment,  387 
comphcations,  389 
deformity  in,  389 
hemorrhage  in,  389 
prosthesis  in,  389 
speech  after,  389 


598 


INDEX 


Jaw,  upper,  resection,  vision  after, 

390 
Jejunostom}',  after-treatment,  460 
Joint,    astragalotarsal,     contracture 
at,  apparatus  for  correcting, 
338 
mice,  arthrotomy  for,  after-treat- 
ment, 336 
finger-,   contracture  of,   318 
flail-like,  331 

operations     on,     ankylotic    union 
in,  331 
solid  union  in,  331 
preparation  of,  171 
resection  of,  instruments  for,  576 
Jugular  vein,  ligation  of,  complica- 
tions after,  393 
Junior  nurse,  25 

second,  27 
Junker's  apparatus,  150 
Jury  mast,  545 

IvAXGAROO  tendon,  sterilization,  55 
Keloid,  311 

after     operation     for     cancer     of 

breast,  429 
pseudo-,  311 
Kemp's  tube  for  colonic  irrigation, 

205 
Kidney,  examination  of,  164 

exploration,  instruments  for,  574 
incision   for    closing,    instruments 
for,  574 
for   exposing,    instruments   for, 
573 
operations  on,  after-treatment  of, 
497 
anm-ia  after,  498 
care  of  wound  after,  502 
fat  necrosis  after,  507 
hematuria  after,  502 
urine  after,  498 
position,  183 
single,  184 
suspension,  instruments  for,  574 
transabdominal   operations   on, 
after-treatment,  482 
Knee,  figure-of-8  bandage,  103 
of  both  knees,  104 
preparation  of,  171 
resection    of,     functional   results, 
336 
Knee-chest  position,  185 
Knives    for    removal    of    plaster-of- 

Paris  bandages,  127 
Kronlein's  craniocerebral  topo- 
graphic hues,  169 

Labor,     induction     of,     after-treat- 
ment, 539 
surgerj'  of,  after-treatment,  540 


Laborde's  method  of  artificial  respi- 
ration, 160 
Laceration     of     cervix,     suture     of, 
after-treatment,  530 
of  perineum,  perineorrhaphy  for, 
after-treatment,  533 
Lacteal  fistula,  treatment,  430 
Lambs'  wool,  48 
Laminectomy,     after-treatment     of, 

542 
Laparotomy,     exploratory,     after- 
treatment  of,  486 
incision,  instruments  for,  560 
closing,  561 
dressing,  561 
making,  560 
retracting,  560 
pads,  49 
sponges,  49 
Laryngeal     paralysis     after     opera- 
tions on  thjToid  gland,  417 
Laryngectomy,    after-treatment    of, 
408 
partial,  after-treatment  of,  409 
Laryngotomy,     after-treatment     of, 

407 
Laryngotracheotomy,  398 
Larynx,  artificial,  409 

Gussenbauer's,    Park's    modifi- 
cation, 411 
intubation  of,  410 
dangers,  412 
removal  of  tube,  412 
technic,  411 
operations  on,  results  of,  406 
stenosis  of,  408 
Lavage  in  after-treatment,  200 
Leg,  figure-of-8  bandage,   long,   72, 
106 
short,  72,  105 
reversed  spiral  bandage  of,  105 
shng  for,  112 
sphnt,  Volkmann's,  189 
ulcer  of,  treatment,  241 
Leube's  nutrient  enema,  201 
Ligament,     broad,     hematocele    of, 

intestinal  obstruction  from,  454 
Ligaments  of  uterus,  operation  on, 
after-treatment,  488 
round,     extraperitoneal     shorten- 
ing, after-treatment,  488 
Ligation  of  arteries,  effect  of,  319 
of    carotid    arterv,    comphcations 

after,  394 
of  femoral  vein,   impending  gan- 

gi'ene  following,  321 
of     jugular     vein,     comphcations 
after,  393 
Ligature,  loosening  of,  hemorrhage 

from,  259 
Lime,  chlorinated,  34 
Lime-water,  42 


INDEX 


599 


Linen  thread,  sterilization,  55 
Swedish,  sterilization  of,  55 
treated  with  celluloid,  steriliza- 
tion, 55 
Lip,    epithelioma    of,    operation   in, 
after-treatment,  367 
plastic  operations  on,  after-treat- 
ment, 367 
Lisfranc's    amputation,    after-treat- 
ment, 339 
Lithotomy  position,  180 
exaggerated,  181 
with  sling  sheet,  182 
Lithotrity,  after-treatment  of,  512 

cystitis  after,  prevention,  513 
Liver,    operations   on,   after-treat- 
ment 475 
Ludwig's  angina,  treatment,  397 
Lung,   decortication  of,   after-treat- 
ment, 439 
examination  of,  164 
operations  involving,   after-treat- 
ment, 440 
hemorrhage  after,  440 
Lymph  phlegmon,  272 
Lymphadenitis,   diphtheritic,   treat- 
ment of,  397 
from  wound  infection,  272 

treatment,  273 
operation  in,  397 
scarlet  fever,  treatment  of,  397 
Lymphangiectasis,  323 
Lymphangioplasty,  323 
Lymphangitis  from  wound  infections 
271 
treatment,  272 
tubular,  272 
Lymphatic    edema    after    operation 
for  carcinoma  of  breast,  428 
on  lymphatic  system,   322  , 
from  wound  infection,  272 
system,  operations  upon,  322 
varix,  324 
Lymphoma,  operation  in,  397 
Lymphorrhea    after    operations    on 

lymphatic  system,  323 
Lymphostasis  from  wound  infections, 
272 

Magnesite  bandage,  131 
Mahgnant     degeneration     in     scar 
tissue,  312 
edema  from  wound  infection,  278 
treatment,  279 
Martin's  India-rubber  bandage,  132 

application,  134 
Mask,  ether,  136 
Masks,  34 

Mastitis  after  operation  for  cancer 
of  breast,  426 
suppurative,   operation  in,   after- 
treatment,  429 


Mastoid,  opening,  instruments  for, 
555 
operations,    after-treatment,    360, 
361 
caries  complicating,  treatment, 

361 
dermatitis  complicating,   treat- 
ment, 361 
extradural  suppuration  in,  362 
Matas'  operation  for  aneurysm,  care 

after,  322 
McBurney's   skin-stretching   hooks, 

307    • 
Meatotomy,  after-treatment  of,  522 
Meltzer's  method  of  intralaryngeal 

insufflation,  160     ' 
Meningeal    hemorrhages,    middle, 
compression   from,    operation  for, 
after-treatment,  355 
Meningitis,  356 

cerebrospinal,  antimeningitis 
serum  in,  250 
Mercury,  bichlorid  of,  41 
as  antiseptic,  287 
gauze  of,  46 
rash  from,  291 
Mesenteric    incarceration    of    duo- 
denum, postoperative,  210 
Mice,  joint,  arthrotomy  for,  after- 
treatment,  336 
Mikulicz's  drain,  47 

operation     on     intestines,     after- 
treatment,  462 
Moist  gangrene  in  amputation,  347 
Moles,  operations  for,  312 
Moleskin  plaster,  58 
Mosetig-Moorhoff  mixture,  44 
Mouth     and     associated     cavities, 
preparation,  172 
operations     on,     after-treatment, 
369 
bronchopneumonia  after,  373 
dangers  after,  373 
phlegmonous    inflammation    of 
tissues  of  neck  after,  374 
Murphy    button    operations,    after- 
treatment,  475 
Murphy's  method  of  proctoclysis,  206 
Muscle,    sternomastoid,    hematoma 

of,  after  operations  on  neck,  397 
Muscles,  operations  upon,  314 
suture  of,  316 
transplantation  of,  314 
Muscular  paralysis  and  contracture, 

ischemic,  296 
Musculospiral  nerve,  injury  of,  175 
Muslin  bandages,  67 
bottle  bags,  38 

hand,  foot,  arm  and  leg  bags,  38 
Myomectomy,    after-treatment    of, 

488 
Myotomy,  316 


600 


IXDEX 


Mj-xedema  after  operations  on  thy- 
roid gland,  420 
treatment,  421 
thyroid  therapy  in,  421,  422 

Xail  cleaner,  34 
files,  34 
scissors,  34 
toe,  ingrown,  314 
Nails,  operations  on,  313 
Nasal  feeding  postoperative,  200 

tamponade,  disadvantages,  371 
Nearthrosis,  331,  336 
Neck,  actinomycosis  of,  397 

and  axilla,  figm-e-of-8  bandage,  80 
bandage,  combined,  81 
operations     on,     after-treatment, 
393 
general  rules,  393 
complications  following,  393 
disturbances  of  respiratory  or- 
gans after,  396 
dressings  for,  396 
edema  of  glottis  after,  397 
hematoma  of  sternomastoid 

muscle  after,  397 
infection  after,  396 
injm'y  of  thoracic  duct  in.  394 
to  brachial  plexus  in,  395 
to  phrenic  nerve  in,  396 
to  spinal  accessorv  nerve  in, 

395       _ 
to  vagus  in,  395 
secondary  hemorrhage  after,  394 
position,  extended,  176 
preparation  of,  171 
Necrosis,    fat,    after    operations    on 
kidney,  507 
of  bone  in  amputation,  344 

in  injuries  of  scalp,  treatment, 
352 
of  flaps  in  amputation,  343 
of  sac  after  heimiotomy,  470 
of  testicle  after  herniotomy,  470 
sj^phiUtic,  of  bone,  operation  for, 
after-treatment,  352 
Needling  of  nerves,  326 
Nephrectomy,  complete,  after-treat- 
ment of,  508 
instruments  for,  574 
partial,  after-treatment  of,  507 
Nephritis  as  cause  of  postoperative 

rise  of  temperature,  221 
Nephrolithotomv,    after-treatment 

of,  503 
Nephrorrhaphv,  after-treatment  of, 

503 
Nephrotomy,  after-treatment  of,  503 
hemorrhage  after,  504 
discharge  of  urine  after,  504 
instruments  for,  574 
urinary  fistula  after,  506 


Nerve,  musculospiral,  injury  of,  175 
phrenic,   injury  to,   in  operations 
on  neck,  396 
Nerves,  anastomosis  of,  324 

for  facial  paralysis,  course  fol- 
lowing, 325 
needhng  of,  326 
peripheral,  operations  on,  324 
resection  of,  324 
stretching  of,  326 
suture  of,  324 

trophic  disturbances  after,  326 
Nervous  system,  operations  on,  324 
Neurectomies,  intracranial,  362 
secondarj'  hemorrhage  in,  363 
result  after,  326 

superficial,    on    face,    after-treat- 
ment, 367 
Neurotomies,  result  after,  326 
Nitrous  oxid  and  ether  anesthesia, 
149 
anesthesia,  148 
Nose,  operations  on,  after-treatment, 
369 
infection  in,  371 
otitis  media  complicating,  371 
prevention  of  adhesions  in,  370 
of  displacement  in,  370 
of  hemorrhage  in,  369 
plastic  operations  on,  after-treat- 
ment, 366 
Novocain,  41 

anesthesia,  157 
Nucleo-proteid,   Beebe's   in  tetany, 

420 
Nurse,  24 
anesthetic  27 
cap  for,  35 
costume  of,  23,  24 
gowns,  35 
junior,  25 

second,  27 
senior,  25 
supply  room,  27 

Oblique  bandage  of  head,  72 
of  jaw,  78 

Obstetric     operations,      after-treat- 
ment of,  539 

Occipito-facial  bandage,  77 

Occlusion    of    carotids,    instruments 
for,  558 

O'Dwyer's  intubation  instruments, 
410^ 

Ogston's  method  of  tarsectomy,  338 

Oil,  ohve,  44 
whale,  44 

Olive  oil,  44 

Oophorectomy,  instruments  for,  561 

Operating  room,  17 

arrangement    of  instrument 
table,  21 


INDEX 


601 


Operating    room,     arrangement    of 
portable  instrument  stand,  22 
of  sponge  table,  21 
costumes,  23 
disinfection,  18 
furniture,  17 

general  considerations,  17 
personnel,  23 
rules,  23 

sinks,  preparation  of,  20 
table.  Fowler's,  19 

position  of  patient  on,  175 
preparation,  19 
Operations,  arrangement  during,  20 
articles  required  for,  553 
cause  of  sudden  death  following, 

303 
field  of,  final  preparation,  186 
in  private  houses,  27 
furniture,  28 
preparation  of  room,  28 
plastic,  308 
shock  from,  302 
Operator's  costume,  24 

gowns,  35 
Opsonic  index,  246,  247 
Opsonins,  246 
Orderly,  27 

costume  of,  24 
OsteomyeHtis,  328,  330 
in  amputations,  347 
Osteotomy  for  genu  valgum,   after- 
treatment,  349 
of  tibia  for  bow-legs,  after-treat- 
ment, 349 
Otitis    media,    operations    on    nose 

complicated  by,  371 
Ovaries,   operations  on,   after-treat- 
ment, 488 
Oxalic  acid  crystals,  40 
solution,  42 

Pads,  laparotomy,  49 
Pagenstecher  thread,  sterilization,  55 
Pails,  dressing,  disinfection  of,  20 
Pain  after  operations  on  abdomen, 
445 
on  rectum  and  anus,  491 
in  after-treatment,  197 
Palate,    cleft,    operation    for,    prep- 
aration, 172 
Pancreas,  fistula  of,  after  operations, 
483 
operations  on,  after-treatment,  482 
fistula  after,  483 
Paper  dressing,  50 
paraffin,  50 
waxed,  50 
Paracentesis,  abdominal,  455 
of  pericardium,  441 

complications,  441 
thoracis,  432 


Paraffin,  44 
paper,  50 

silk,  sterilization,  56 
Paralysis,  constriction,  294 

due  to  operative  traumatism,  293 
facial,     nerve     anastomosis     for, 
course  following,  325 
trismus  with,   from  wound  in- 
fection, 281 
hysterical,  294 
laryngeal,     after     operations     on 

thyroid  gland,  417 
muscular,  and  contractirre,  296 
of  entire  extremity,  294 
postoperative,  293 
postural,  294 

respiratory,    in    chloroform    anes- 
thesia, 147 
in  ether  anesthesia,  144 
Paraphimosis,  operations  for,  after- 
treatment,  523 
Parathyroids,  transplantation  of,  in 

tetany,  420 
Paresis,  intestinal,   after  operations 
on  abdomen,  451 
of  affected  loop  after  operation  for 

incarcerated  hernia,  473 
vascular,  hemoi-rhage  from,  260 
Park's     modification     of     Gussen- 

bauer's  artificial  larynx,  411 
Parotid  fistula  after  operation,  366 
gland,  operations  on,  after-treat- 
ment, 366 
Parotitis,  facial  expression  in,  196 
postoperative,  196 
treatment  of,  197 
Parulis,  after-treatment,  383 
Patella,  fracture  of,  after-treatment, 
341 
suture  of,  instruments  for,  578 
Patient,  cap  for,  35 

general  preparation,  164 
local  preparation,  168 

general  directions,  168 
position  of,  on  operating  table,  175 
Pelvis,  preparation  of,  171 

section  of,  after-treatment,  540 
Penis,    amputation    of,    after-treat- 
ment, 523 
extirpation     of,     after-treatment, 
524 
Percentage  table  of  solutions,  56 
Pericarditis     after     operations     on 
heart,  441 
on  thorax,  432 
Pericardium,  paracentesis  of,  441 

complications,  441 
Perineal  cystotomy.     See  Cystotomy, 
perineal. 
fistula   after  perineal   cystotomy, 
519 
prostatectomy,  522 


602 


INDEX 


Perineal  prostatectomy.     See  Pros- 
tatectomy, perineal. 
section  in  stone  cases,  instruments 
for,  572 
instruments  for,  572 
without  a  guide  in  impassable 
stricture,  instruments  for,  572 
straps,  115 

urethra,     suture     of,     after-treat- 
ment, 523 
Perineorrhaphy,   after-treatment  of, 
533 
care  in  operating,  535 
instruments  for,  569 
interference  with  wound  healing, 
534 
Perineum,     laceration    of,  perineor- 
rhaphy for,  after-treatment,  533 
section  of,  after-treatment,  540 
Peripheral  nerves,  operations  on,  324 
Peristaltic  hormone,  451 
Peritoneum,  oozing  from,  after  ope- 
rations on  abdomen,  450 
Peritonitis  after  abdominal  section, 
446,  447 
after    operation    for    incarcerated 

hernia,  472 
appendicitis   with,    operation  for, 

after-treatment,  462,  463 
facial  expression  in,  196 
postoperative    intestinal    obstruc- 
tion from,  454 
tuberculous,   operation  for,  after- 
treatment,  487 
Peritonsillar   abscess,    operation   in, 

after-treatment,  377 
Permanganate    of    potassium    solu- 
tion, 42 
Pharyngotomy,  after-treatment,  413 
Phlebitis,     iliac,     with    thrombosis, 
after    operations    on    abdomen, 
449 
of  femoral  vein  after  herniotomy, 

471 
of  internal  saphenous  vein,  300 
sinus    in   intracranial    operations, 
362 
Phlegmon,  235 
fecal,  489 

intermuscular,  236 
lymph,  272 
subcutaneous,  236 
tendinous,  237 
Phlegmonous  inflammation  of  scalp, 
352 
of  tissues  of  neck  after  opera- 
tions on  mouth,  374 
Phrenic  nerve,  injury  to,  in  opera- 
tions on  neck,  396 
Picric  acid  poisoning,  289 
Pilcher's  retractors,  399 
Pitchers,  disinfection  of,  20 


Plaster,  adhesive,  58 

abdominal  scultetus,  61 
method  of  removal,  61 
bandage,  67 

bridge  elbow  splint,  332 
moleskin,  58 
resin,  58,  60 
rubber,  58,  60 

splint,  stocking  bivalve,  121 
sphnts,  129 
zinc-oxid,  61 
Plaster-of-Paris  bandage,  120 
application,  125 

precautions  in,  123 
manufacture,  122 
removal,  127 
cast,  instruments  for  removal,  580 
compresses,  120 
outfit,  580 
splints,  121 
Plastic  operations,  308 

on  cheek,  after-treatment,  366 
on  female  genitals,  intercourse 

after,  539 
on  lip,  after-treatment,  367 
on  nose,  after-treatment,  366 
on  scalp  after-treatment,  351 
on  ureters,  after-treatment,  508 
Pleura,  wounds  of,   healing  process 

in,  433 
Pleural  cavity,  opening  of,  compli- 
cations from,  432 
Pleurectomy,  position  for  resecting 

ribs  in,  178 
Pleuritis  after  operations  on  thorax, 
432 
serous,  after  operations  on  thorax, 

433 
suppurative,  drainage  in,  433 
operation    in,     after-treatment, 
433 
Plexus,     brachial,     injuries     to,     in 
operations  on  neck,  395 
suture  of,  treatment  after,  326 
Plugs,  Bernay's,  370 
Plummer's   method   of  diagnosis  of 

esophageal  diverticula,  172 
Pneumococcus  vaccines,  250 
Pneumonia  as  cause  of  postoperative 
rise  of  temperature,  221 
facial  expression  in,  196 
foreign  body,  218 
hypostatic,  218,  221,  222 
in  amputations,  347 
postoperative,  218 

treatment  of,  219 
septic,  219 
Pneumothorax  from  opening  pleural 

cavity,  433 
Poisoning  from  carbolic  acid,  treat- 
ment, 286 
from  picric  acid,  289 


INDEX 


603 


Poisoning,  iodoform,  288 

systemic,  288 
Poroplastic  felt  corsets  in  tubercu- 
lous spondylitis,  549 
Portable  instrument  stand,  arrange- 
ment, 22 
Position,  dorsal,  180 

abdominal  binder  applied,  190 
operation  suit,  175 
ready     for     final     preparation, 
186 
for  operation,  187 
elevated  head  and  trunk,  193 
for  amputation  of  breast,  179 
,  for  operations  on  thyroid  gland, 
177 
on  upper  abdomen,  179 
for  resecting  ribs  in  pleurectomy, 

178 
for  thoracotomy,  179 
I    head  and  trunk,  elevated,  193 
dependent,  175 
kidney,  183 

single,  184 
knee-chest,  185 
lithotomy,  180 
exaggerated,  181 
with  sling  sheet,  182 
neck,  extended,  176 
of  "^  patient     in     after-treatment, 
191 

on  operating  table,  175 
Sims',  183 
Trendelenburg,  180 

reversed,  180 
ventral,  184 
Post-anesthetic  vomiting,  195.     See 

also  Vomiting,  post-anesthetic. 
Postoperative  paralysis,  293 
Postural  paralysis,  294 
Potash,  bichromate  of,  41 

solution,  bichromate  of,  43 
Potassium    permanganate    crystals, 
40 
solution,  permanganate  of,  42 
Pott's  disease,  forcible  corrections  of 
deformity  in,  after-treatment, 
543 
operation   for,    after-treatment, 

544 
Schapps'    apparatus   for   treat- 
ment of,  550 
Powders,  39 

Pregnancy,  abdominal  operations  in, 
after-treatment,  540 
extra-uterine,  instruments  for,  561 
operation  for,    after-treatment, 
488 
surgery  of,  after-treatment,  539 
Pregnant   uterus,   impacted,   reduc- 
tion of,  after-treatment,  539 
Pre-operative  preparation,  163 


Pressure  bandages,  63,  131 
gangrene,  local,  297 
wound,    complications    result   of, 
293 
Primary  dressing,  163 
Private  houses,  operations  in,  27 
furniture,  28 
preparation  of  room,  28 
Proctoclysis,  206 

drop  regulator  in,  208 
Murphy's  method,  206 
Prolapse,  cerebral,  357 

of  rectum,  instruments  for,  576 
recurrence,  after  operation,  496 
Prostatectomy,  perineal,  after-treat- 
ment of,  520 
care  of  wound,  520 
epididymitis  after,  522 
instruments  for,  573 
perineal  fistula  after,  522 
suprapubic,     after-treatment     of, 
520 
Prostatic     abscess,     operation     for, 

after-treatment,  514 
Prosthesis   after  resection   and  dis- 
articulation of  lower  jaw,  393 
in  amputations,  348 
in  resection  of  jaw,  389 
Protective,  green  silk,  51 
sterilization  of,  51 
Protectors,  37 
anus,  37 

sterilization  of,  37 
sterilization  of,  37 
Pseudo-keloid,  311 
Pubiotomy,  after-treatment  of,  540 
Pulse,  postoperative,  222 
Puncture  of  bladder,  508 
Pus  basins,  disinfection,  20 
Pyelonephrosis,  nephrotomy  for, 

after-treatment,  505 
Pyemia  from  wound  infection,  275 
Pylorectomy,  after-treatment,  461 
Pyogenic  membrane  in  granulation, 
'239 

QuiNiN,  rash  from,  291 

Ranula  operations,  after-treatment, 

375 
Rashes  after  enema,  291 
due  to  drugs,  291 
ether,  292 
septic,  292 
surgical,  289 
causes  of,  290 
diagnosis  of,  289 
treatment  of,  291 
types  of,  290 
Rectal  feeding,  postoperative,  201 
Rectovaginal  fistula,  operation  for, 
after-treatment,  533 


604 


IXDEX 


Rectum    and    anus,    operations    on, 
after-treatment,  489 
diet  after,  497 
hemorrhage  after,  490 
incontinence    of    feces    after, 

496 
instruments  for,  575 
pain  after,  491 
sepsis  after,  489 
stenosis  after,  495 
ui'inarv     distm-bances     after, 

491' 
wound  treatment,  491 
extirpation  of,  after-treatment,  494 
by  abdominoperineal  route,  in- 
struments for,  173 
preparation  of,  173 
prolapse  of,  instruments  for,  576 

recurrence,  after  operation,  496 
wounds  of,  after-treatment,  495 
Recm-rent  bandage,  72 
of  foot,  109 
of  head,  73 
of  stump,  72 
Redressing  of  wounds,  227 
Regeneration    in    spinal    cord    after 

injuries,  327 
Resecting  ribs  in  pleiu-ectomy,  posi- 
tion for,  178 
Resection     and     disarticulation     of 
lower    jaw,     after-treat- 
ment, 390 
prosthesis  after,  393 
suffocation  after,  392 
of    alveolar    process,    after-treat- 
ment, 383 
of  ankle-joint,  after-treatment,  337 

result,  337 
of  breast,  after-treatment,  429 
of    elbow-joint,     after-treatment, 

332 
of  hip  for  tuberculosis,  after-treat- 
ment, 333 
functional  results,  335 
of  intestine,  instruments  for,  562 
of  joints,  instruments  for,  576 
of   knee-joint,    functional  results, 

336 
of  lower  jaw,  instruments  for,  555 
of  nerves,  324 

of    one-half    of    upper    jaw.     See 
Jaw,  upper,  resection  of  one-half. 
of  rib,  after-treatment,  431 

instruments  for,  559 
of  sternum,  after-treatment,  431 
wounds,  after-treatment,  330 
Resin  plaster,  58.  60 
Respiration,  artificial,  158 
Laborde's  method.  160 
Sylvester's  method,  159 
disturbances   of,    after  operations 
on  thj-roid  gland,  417 


Respiration,  postoperative,  222 
Respiratory     organs,     disturbances, 
after  operations  on  neck,  396 
paralvsis  in  chloroform  anesthesia, 
147 
in  ether  anesthesia,  144 
Retention    of    urine   in    after-treat- 
ment, 213 
Retractor  bandages,  118 
three-tailed,  118 
two-tailed,  118 
Retrocatheterization,  510 
Retropharyngeal  abscess,  operation 

in,  after-treatment,  377 
Reversed  spiral  bandage,  70 
of  finger,  93 
of  foot,  107 

of  lower  extremit}',  105 
of  upper  extremity,  87 
Trendelenburg  position,  180 
Rib,  fracture  of,  operation  in,  after- 
treatment,  430 
resection  of,  after-treatment,  431 
in    pleurectomj-,    position    for, 

178 
instruments  for,  559 
Rolando's  fissure,  location  of,  169 
Roller  bandages,  63 

abdominal,  dimensions  of,  67 
chest,  dimensions  of,  67 
double,  63 

dimensions  of,  67 
general  rules  in  apphcation,  67 
varieties,  68 
Roller-bandage  box,  66 
machine,  foot,  65 
hand,  64 
Room,  anesthetic,  135 
furniture  of,  135 
instrument,  31,  32 
operating,  17.     See  also  Operating 

room. 
supply,  31,  32 
Round     ligaments,     extraperitoneal 
shortening  of,  after-treatment,  488 
Rubber  aprons,  34 
bandages,  52 

sterilization,  52 
bolsters,  5 

sterilization,  52 
dam,  sterilization,  51 
di-ainage  tubes,  50 

sterilization,  50 
gloves,  sterihzation,  35 
goods,  50 
plaster,  58,  60 
sheeting,  38 
tissue  di-ains,  47 
Ruptm-e  of  wound  after  operations 

on  abdomen,  448 
Rvall's    drop    regulator    in    procto- 
'clysis,  208 


INDEX 


605 


Salicylic  acid,  rash  from,  291 
Saline    infusion,    intravenous,    263. 
See     also     Intravenous      saline 
infusion. 
powders,  39 
solution,  normal,  42 
Salpingo-oophorectomy,  after-treat- 
ment of,  488 
instruments  for,  561 
Sandbags,  58 

Saphenous  vein,   internal,   phlebitis 
of,  300 
varicosities  of,  321 
Sapo  viridis,  33 
Saw,  French,  for  removal  of  plaster- 

of-Paris  casts,  127 
Saws  for  removal  of  plaster-of-Paris 

casts,  128 
Sayre's  apparatus  for  correction  of 
talipes  equinus,  338 
plaster-of-Paris  jacket,  547 
shoe  for  clubfoot,  338 
Scabbard  trachea,  position  of  patient 

with,  174_ 
Scalp,    erysipelas    of,    phlegmonous 
inflammation    and,    differentia- 
tion, 353 
operations     on,     after-treatment, 
351 
instruments  for,  553 
phlegmonous  inflammation  of,  352 
erysipelas  and,  differentiation, 
353 
plastic  operations  on,  after-treat- 
ment, 351 
wounds  of,  after-treatment,  351 
erysipelas  complicating,  352 
Scar  tissue,  complications  occurring 

in,  310 
Scarlet  fever,  surgical,  290 
Scars,  latent  infections  in,  312 

malignant  degeneration  in,  312 
Schapps'  apparatus  for  treatment  of 

Pott's  disease,  550 
Schede's  thoracoplasty,   after-treat- 
ment, 439 
Schimmelbusch's  sterilizer,  39 
Schleich's  solution,  156 
Scissors,  bandage,  68 

nail,  34j 
Scoliosis,  secondary,  after  operation 
in  thoracic  empyema,  438 
Shaffer's  brace  in,  551,  552 
treatment  of,  550 
Volkmann's  cushion  in,  552 
Screen  covers,  38 

Scrotum,    operations    on,    cellulitis 
after,  525 
complications,  524 
hematoma  after,  524 
Scrub-up  tray,  20 
Scultetus  bandage,  118 


Secondary  suturing,  229 
Secretions,  retention  of,  in  wounds, 
by  blockage  of  drain,  239 
wound,  retention  of,  234 
with  tension,  235 
Self -retaining  drainage-tube,  51 
Semilunar    cartilage,    detached,    ar- 
throtomy  for,  after-treatment,  336 
Senile  gangrene  in  amputations,  347 
Senior  nurse,  25 
Sepsis   after   operations   on  rectum 

and  anus,  489 
Septic  pneumonia,  219 

rash,  292 
Septicemia    from    wound    infection, 
273 
treatment,  274 
Septum,  deviated,   instruments  for, 

557 
Serpentine  bandage  of  foot,  107 

of  great  toe,  110 
Serum,  antimeningitis,  250 

antitoxin,  250 
Shaffer's  brace  in  scoliosis,  551,  552 
Sheets,  sterilization  of,  38 
Shock,  302 

after  operations  on  heart,  440 
fat  embolism  and,  differentiation, 

302 
in  amputation,  343,  346 
intravenous     saline    infusion    in, 

263,  265 
surgical,    relation   of   acapnia   to, 

161 
treatment  of,  303 
Shoe,  Sayre's  for  clubfoot,  338 
Shoulder,  ascending  spica  bandage, 
81 
descending  spica  bandage,  82 
preparation  of,  171 
Silk,  paraffin,  sterilization  of,  56 

sterilization  of,  55 
Silkworm-gut,  steriUzation  of,  56 
Silver  wire,  sterilization,  56 
Sims'  position,  183 
Singultus,  postoperative,  209 

treatment  of,  209 
Sinks,  preparation  of,  20 
Sinus,  Beck's  bismuth  paste  in,  254. 
See  also  Beck's  bismuth  paste. 
curette,  Delatour's,  244 
formation  in  infected  wound,  244 
frontal,     opening    of,    after-treat- 
ment, 372 
operations  on,   after-treatment, 
369 
phlebitis    in    intracranial    opera- 
tions, 362 
syringe,  245 
Skin,    care   of,    in   neighborhood   of 
wound,  245 
cocain  anesthesia  of,  157 


606 


INDEX 


Skin,  operations  upon,  304 
preparation  of,  168 
sutures,  removal  of,  technic,  227 
Skin-gi'afting,  306 

basket  strapping  dressing  for,  308 
instruments  for,  579 
open  treatment,  308 
Skin-stretching  hooks,  ]McBurney's, 

307 
Skull,  fractures  of,  compound,  with- 
out depression,  initial  treatment, 
353 
Sling,  arm-.  111 

leg-,  112 
Sluggish  granulation,  239 
Soap,  33 

Soda,  carbonate  of,  41 
Sodium  bicarbonate,  43 
carbonate,  34 
chlorid,  41 
Softening,  cerebral,  after  removal  of 

brain  tumor,  356 
Sole  of  foot,  preparation,  171 
Soluble-glass  bandage,  130 
Solutions,  41 

percentage  table,  56 
Sounds,  passage  of,  217 
Speech  after  amputation  of  tongue, 
382 
after  resection  of  one-half  of  upper 
jaw,  389 
Sphvgmomanometer,     J  anew  ay's, 

165 
Spica  bandage,  71 

ascending,  double,  of  groin,  101 
of  shoulder,  81 
single,  of  gi'oin,  98 
descending,  double,  of  groin,  103 
of  shoulder,  82 
single,  of  groin,  101 
of  foot,  107 
of  gi'eat  toe,  110 
of  thumb,  90 
Spina  bifida,    operations  for,   after- 
treatment,  544 
Spinal  accessory  nerve,  injmy  to,  in 
operations  on  neck,  395 
analgesia,  153 

rules  for  making  injection,  154 
cord    and    posterior    nerve    roots, 
operations  on,  327 
regeneration   in,    after  injuries, 
327 
Spiral  bandage,  69 
of  chest,  95 
of  finger,  90,  93 
of  foot,  106 
reversed,  70 
of  finger,  93 
of  foot,  107 

of  lower  extremity,  105 
of  upper  extremit}',  87 


Spleen,    operations    on,    after-treat- 
ment, 481 
thrombosis  of  splenic  vein  after, 
482 
Splenectomy,  after-treatment,  482 
secondarj^  hemorrhage  after,  482 
Splenic    vein,    tlii-ombosis    of,    after 

operation  on  spleen,  482 
Splenopexy,  after-treatment,  482 
Splenotomj',  after-treatment,  481 

secondarj'  hemorrhage  after,  481 
Sphnt,  58 
Asch's,  371 
Bavarian,  121 
elbow,  332 
interdental,  384 
leg,  Volkmann's,  189 
plaster,  129 

stocking  bivalve,  121 
plaster-of-Paris,  121 
Taylor's  hip,  335 
Spondyhtis,  cervical,  operations  for, 
after-treatment,  544 
tuberculous,   poroplastic  felt  cor- 
sets in,  549 
treatment  of,  constitutional,  550 
mechanic,  545 
Sponge  table,  arrangement,  21 
Sponges,  48 
hand,  48 
laparotomj",  49 
stick,  49 
Staphylococcus     vaccines,     dosage, 

249 
Staphvlorrhaphv,  a  f  t  e  r-treatment, 
378_ 
comphcations,  379 

treatment  of,  380 
failure  of  union  in,  379 
instruments  for,  556 
Starch  bandage,  67,  129 

application,  130 
Stenosis  after  operations  on  rectum 
and  anus,  495 
cervical,    Dudley's   operation  for, 

after-treatment,  531 
of    intestine    after    operation    for 

incarcerated  hernia,  474 
of  larynx,  408 

of  trachea  after  tracheotomy,  406 
Sterile  feeding,  postoperative,  202 

water,  43 
Sterilization  of  anus  protectors,  37 
of  blankets,  38 
of  braided  catgut,  54 
of  brushes,  33 
of  catgut,  52 

alcohol  method,  52 
Bartlett's  method,  55 
of  chromic  catgut.  No.  1,  54 

Xo.  2,  54 
of  dressing  materials,  38 


INDEX 


607 


Sterilization  of  filiform  bougies,  51 
of  gauze,  38,  44 
of  glass  goods,  52 
of  gowns,  38 

of  green  silk  protective,  51 
of  hands,  187 
of  horsehair,  56 
of  instruments,  31 
of  iron  wu'e,  56 
of  kangaroo  tendon,  55 
of  linen  thread,  55 

treated  with  celluloid,  55 
of  Pagenstecher  thread,  55 
of  paraffin  silk,  56 
of  protectors,  37 
of  rubber  bandages,  52 
dam,  51 

drainage  tubes,  50 
gloves,  35 
of  sheets,  38 
of  silk,  55 

of  silkworm-gut,  56 
of  silver  wire,  56 
of  Swedish  linen  thread,  55 
of  tourniquets,  52 
of  towels,  37,  38 
of  utensils,  191 
Sterilizer,  Arnold,  39 

Schimmelbusch's,  39 
Sternomastoid  muscle,  hematoma  of, 

after  operations  on  neck,  397 
Sternum,    resection    of,    after-treat- 
ment, 431 
Stick  sponges,  49 
Stitch  abscess,  234 

as  cause  of  postoperative  rise  of 

temperature,  222 
treatment,  234 
Stocking  bivalve  plaster  sphnt,  121 
Stomach  and  duodenum,  dilatation 
of,  postoperative,  210 
treatment,  212 
operations     on,     after-treatment, 

455 
preparation  of,  172 
tube  in  after-treatment,  199 
Stone  cases,  instruments  for,  572 

perineal  section  in,  instruments 
for,  572 
Strapping,  basket,  for  skin-grafting, 
308 
for  varicose  ulcers,  241 
for  varicose  ulcers,  241 
Streptococcus  vaccines,  dosage,  249 
Stretching  of  nerves,  326 
Stricture  of  esophagus  after  esoph- 
agectomy, 414 
of    urethra,     excision    of,     after- 
treatment,  523 
Strychnine,  rash  from,  291 
Stump,   bandaging,   in  amputation, 
345 


Stump,    painful    conditions    of,    in 
amputation,  344 
recurrent  bandage,  72 
Subcutaneous     feeding,     postopera- 
tive, 202 
phlegmon,  236 
tissues,  operations  upon,  304 
Subpectoral    abscess,    operation    in, 

after-treatment,  430 
Suffocation  after  resection  and  dis- 
articulation of  lower  jaw,  392 
Supphes,  preparation  of,  30 
Supply  room,  31,  32 

nurse,  27 
Suppurative   hepatitis    after   opera- 
tions on  abdomen,  449 
mastitis,  operation  in,  after-treat- 
ment, 429 
pleuritis,  drainage  in,  433 
operation  in,  after-treatment,  433 
Suprapubic  cystotomy,  instruments 
for,  573 
with  temporary  drainage,  after- 
treatment,  511 
without    drainage,    after-treat- 
ment, 511 
drain.  Bangs,  512 
drainage    of    bladder,    Dawbarn's 

apparatus  for,  512 
prostatectomy,  after-treatment  of, 
520 
Suprasymphyseal  section,  after- 
treatment,  541 
Surgeon's  cap,  35 
Surgical  shock,  relation  of  acapnia 

to,  161 
Suspension  operations  on  abdominal 

viscera,  after-treatment,  462 
Suture  of  brachial  plexus,  treatment 
after,  326 
of    laceration     of     cervix,     after- 
treatment,  530 
of  muscles,  316 
of  nerves,  324 

trophic  disturbances  after,  326 
of  patella,  instruments  for,  578 
of    perineal    urethra,    after-treat- 
ment, 523 
of  tendons,  314 
skin,  removal  of,  technic,  227 
Sutm-ing,  secondary,  229 
Swedish  linen   thread,   steriUzation, 

.55 
Sylvester's  method  of  artificial  res- 
piration, 159 
Sylvius,  fissure  of,  169 
Symphysiotomy,  after-treatment  of, 

540 
Syndactylism,  312 
Syphilitic  necrosis  of  bone,  operation 

for,  after-treatment,  352 
Syringe,  sinus,  245 


608 


INDEX 


Table,  instrument,  arrangement  of, 
21 
portable,  arrangement  of,  22 
operating.  Fowler's,  19 
position  of  patient  on,  175 
preparation  of,  19 
sponge,  arrangement  of,  21 
Talipes  equinus,  operation  for,  after- 
treatment,  338 
Savre's  apparatus  for  correcting, 
338 
Tampon,  graduated,  49 

umbrella,  47 
Tamponade,     nasal,     disadvantages 

of,  371 
Tapping  hydrocele,  525 
Tarsectomy,  338 

Ogston's  operation,  338 
Taylor's  brace  for  Pott's  disease,  547 

hip  splint,  335 
T-bandage,  112 
abdominal,  115 
double,  112 
of  chest,  113 
single,  112 
Teeth,     extraction     of,     after-treat- 
ment, 383 
Temperature,  postoperative,  220 
rise  of,  postoperative,  221 
bronchitis  as  cause,  221 
nephritis  as  cause,  221 
pneumonia  as  cause,  221 
stitch  abscess  as  cause,  222 
wound  infection  as  cause,  222 
Tendinous  phlegmon,  237 
Tendon,   kangaroo,   sterilization  of, 

55 
Tendons,  operations  upon,  314 
suture  of,  314 
transplantation  of,  314 
Tenorrhaphy,  314 
Tenosynovitis,  tuberculous,  317 
Tenotomy,  316 

Testicle,  gangrene  of,  after  operation 
for  varicocele,    525 
necrosis  of,  after  herniotomy,  470 
undescended,  operation  for,  after- 
treatment,  525 
Tetanus  antitoxin,  250 
from  wound  infection,  280 

differential  diagnosis,  282 
treatment,  281 
Tetany  after  operations  on  thyroid 
gland,  418 
treatment,  419 
Thermocautery,  56 

wounds,  245 
Thiersch  gauze,  46 
powders,  41 
solution,  42 
Thigh,    amputation   through,    after- 
treatment,  348 


Thirst  after  operation,  198 

treatment,  198 
Thomas'  padded  leather  collar,  546 
Thoracic  duct,  injury  of,  in  opera- 
tions on  neck,  394 
empyema.     See    Empyema,    thor- 
acic. 
Thoracoplasty,  after-treatment,  439 
Thoracotomy  position,  179 
Thorax,   operations   on,   after-treat- 
ment, 424 
paracentesis  of,  432 
preparation  of,  171 
Thread,  linen,  sterilization  of,  55 
Swedish,  sterilization  of,  55 
treated  with  celluloid,  steriliza- 
tion, 55 
Pagenstecher,  sterilization  of,  55 
Throat,  cut,  instruments  for,  558 
Thrombosis,  321 

after  operations  on  abdomen,  449 
of  femoral  vein,  299 
treatment,  300 
of  splenic  vein  after  operations  on 
spleen,  482 
Thumb,  spica  bandage,  90 
Thyroid    gland,    adenoma    of,    enu- 
cleation   of,    after-treatment, 
418 
cysts  of,  enucleation  of,    after- 
treatment,  418 
operations  on,  after-treatment, 
415 
exophthalmic     cases,     415, 
416 
cachexia    strumipriva    after, 

420 
care  of  wound,  416 
complications    due    to    inter- 
ference   with    function    of 
thyroid     and    parjithyroid 
bodies,  418  ;", 

disturbances     of    retpiration 

after,  417  I 

laryngeal  paralysis  alter,  417 
myxedema  after,  42(" 

treatment,  421 
position  for,  177 
preparation,  174 
secondary  hemorrhage  after, 

417 
tetany  after,  418 
treatment,  419 
tumors,    enucleation    of,    after- 
treatment,  418 
therapy  in  myxedema,  421,  422 
Thyroidectomy,  anesthesia  in,  138 
Tibia,    osteotomy   of,    for   bow-legs, 

after-treatment,  349 
Tiemann's  brace  in  genu  a  algum,  350 
Tissues,    special,    operat  qns    upon, 
303 


INDEX 


609 


Toe,  great,  serpentine  banda^f)  HO 
spica  bandage,  110 
nail,  ingrown,  314 
Toes,    amputation    of,    after-treat- 
ment, 348 
Tongue,  amputation  of,  after-treat- 
ment, 382 
edema  of  glottis  after,  382 
speech  after,  382 
Tongue-tie,     operation     for,     after- 
treatment,  375 
Tonsillectomy,  after-treatment,  375 
for     carcinoma,     after-treatment, 

377 
instruments  for,  556 
voice  after,  377 
Torticollis,     operation     for,     after- 
treatment,  422 
Tourniquets,  52 
India-rubber,  132 
sterilization  of,  52 
Towels,  37 

sterilization  of,  37,  38 
Toxemia,   intestinal,   in   after-treat- 
ment, 203 
postoperative,  224 
Trachea,   scabbard,  position  of  pa- 
tient with,  174 
stenosis  of,  after  tracheotomy,  406 
Tracheal  insufflation  anesthesia,  150 

technic  of,  151 
Trachelorrhaphy,  after-treatment  of, 
530 
instruments  for,  568 
Tracheotomy,  398 

after-treatment,  390,  401 

care  of  wound,  401 

choice  of  operation,  398 

course  following    introduction    of 

tube,  402 
dilate   ion  after,  406 
displa  ement  of  tube,  403 
granu '  5ma  after,  406 
hemorrhage  in,  404 
instru)  lents  for,  557 
low,  31^8 

occlusion  of  tube  by  mucus,  402 
rapid,  398 

removal  of  cannula,  405 
replacement  of  tube,  403 
secondary  hemorrhage  after,  404 
stenosis  of  trachea  after,  406 
technic,  398 
tubes,  400 

method  of  retaining  in  position, 
401 
ulcers  after,  404 
wound  diphtheria  in,  405 
infection  in,  405 
Transfusion,  direct,  of  blood,  266 
Bre\^-er's  method,  269 
Crile's  method,  267 
39 


Transfusion,  direct,  dangers  of,  266 
Elsberg's  method,  270 
hemolysis  in,  266 
instruments  for,  580 
Transplantation  of  muscles,  314 

of  tendons,  314 
Traumatism,     operative,     paralysis 

due  to,  293 
Trendelenburg  cannula,  150 
position,  180 
reversed,  180 
Trephine   openings,    wound  healing 

in,  358 
Trephining,  after-treatment  of,  354 

instruments  for,  554 
Treves'   operation  for  caries,   after- 
treatment,  544 
Triangular  bandage  of  groin,  114 

bandages,  113 
Trigeminus,  excision  of,  instruments 

for,  554 
Trismus  with  facial  paralysis  from 

wound  infection,  281 
Tubal  abortion,  operation  for,  after- 
treatment,  488 
Tuberculosis,  adenectomy  for,  324 
of  hip,   resection  for,   after-treat- 
ment, 333 
functional  results,  335 
Tuberculous  bone  disease,  operation 
for,  after-treatment,  352 
peritonitis,    operation    for,    after- 
treatment,  487 
spondylitis,    poroplastic   felt   cor- 
sets in,  549 
treatment,  constitutional,  550 
mechanic,  545 
tenosynovitis,  317 
Tubular  lymphangitis,  272 
Tumor,  benign,  of  bone,  328 

of  brain,  operation  for,  after-treat- 
ment, 355 
cerebral  softening  after,  356 
edema  after,  356 
of  thyroid,  enucleation  of,   after- 
treatment,  418 


Ulcers  after  tracheotomy,  404 

varicose,  treatment  of,  241 
Umbilical    hernia,    instruments   for, 
566 
operation  for,    after-treatment, 
471 
Umbrella  tampon,  47 
Undescended  testicle,  operation  for, 

after-treatment,  525 
Uranoplasty,  after-treatment,  378 
complications,  379 

treatment  of,  380 
failure  of  union  in,  379 
instruments  for,  556 


610 


IXDEX 


Ureters,  injury  to,  in  vaginal  hyster- 
ectomj^,  538 
pperations     on,     after-treatment, 
497 
anuria  after,  498 
urine  after,  498 
plastic  operations  on,  after-treat- 
ment, 508 
Urethra,    perineal,    suture  of,  after- 
treatment,  523 
stricture    of,     excision    of,     after- 
treatment,  523 
Urethral  caruncle,  excision  of,  after- 
treatment,  535 
instruments  for,  569 
fistula,  closure  of,  after-treatment, 
523 
operation   for,    after-treatment, 
532 
Urethrotomy,  internal,  instruments 

for,  571 
Urinary    apparatus,    operations    on, 
after-treatment,  497 
preparation  of,  173 
disturbances   after   operations   on 

rectum  and  anus,  491 
fistula  after  nephi'otomy,  506 
Urination,  difficulty  of,  after  herni- 

otom\',  471 
Urine    after    operations    on   m-inary 
apparatus,  498 
discharge    of,    after    nephrotomy, 

504 
in  after-treatment,  213 
infiltration  of,  after  operations  on 

bladder,  510 
retention    of,    in    after-treatment, 
213 
Urticaria,  surgical,  290 
Utensils,  sterihzation  of,  191 
Uterus  and  adnexa,  intra-abdominal 
operations    on,    after- 
treatment,  487 
drainage  in,  487 
hgaments  of,  operations  on,  after- 
treatment,  488 
lower  zone,  section  of,  after-treat- 
ment, 540 
pregnant,  impacted,  reduction  of, 
after-treatment,  539 

Vaccixe  therapy,  dosage  in,  248 
for  infected  wound,  246 
negative  phase,  247 
positive  phase,  247 
Vaccines,  dosage  of,  248 
gonococcus,  250 
pneumococcus,  250 
preparation  of,  247 
staphjdococcus,  dosage  of,  249 
streptococcus,  dosage  of,  249 
Vagina,  preparation  of,  171 


Vaginal     Cesarean     section,     after- 
treatment,  540 
hvsterectomy,     a  f  t  e  r-treatment, 
537 
complications,  538 
infection  in,  539 
injury  to  ureter  in,  538 
instruments  for,  569 
intestinal  obstruction  in,  539 
h^'sterotomy,  anterior,  after-treat- 
ment of,  540 
operations,  instruments  for,  567 
Vagus,  injur}'  to,  in  operations  on 

neck,  395 
Valvular  cecostoniA',  intestinal  irri- 
gation by  means  of,  465 
Varicocele,  instruments  for,  570 
operations    for,     after-treatment, 
525 
gangrene  of  testicle  after,  525 
Varicose  ulcers,  treatment,  241 

veins,  instruments  for,  578 
Varicosities  of  saphenous  veins,  321 
Varix,  lymphatic,  324 
Vascular  paresis,  hemorrhage  from, 
260 
system,  operations  on,  319 

disturbances     of     circulation 

complicating,  319 
secondary  hemorrhage    com- 
plicating, 319 
Vaselin,  44 

Vein,  femoral,  ligation  of,  impending 
gangrene  following,  321 
thrombosis  of,  299 
treatment,  300 
jugular,  hgation  of,  compUcations 

after,  393  _ 
saphenous,  internal,   phlebitis  of, 

300 
splenic,  thi'ombosis  of,  after  opera- 
tion on  spleen,  482 
Veins,    saphenous,    varicosities    of, 
321 
varicose,  instruments  for,  578 
Velpeau  bandage,  83 
Venous  blood,  prevention  of  return 

of,  298 
Ventral  hernia  after  operations  on 
abdomen,  448 
instruments  for,  566 
operation  for,    after-treatment, 
471 
position,  184 
Vertebrae,  fracture  dislocation,  ope- 
rations for,  after-treatment,  542 
fractm-es  of,  operations  for,  after- 
ment,  542 
Vertebral    column,     operations    on, 

after-treatment,  542 
Vesicovaginal  fistula,  operation  for, 
aft-er-treatment,  532 


INDEX 


611 


Viscera,  abdominal,  suspension  ope- 
rations on,  after-treatment,  462 
Vision  after  resection  of  jaw,  390 
Visitors,  costume  of,  24 
Voice  after  removal  of  tonsUs,  377 
Volkmann's  block,  68 
cushion  in  scoliosis,  552 
method  of  extension  in  recumbent 

position,  546 
posterior  leg  splint,  189 
Vomiting  after  gastro-enterostoray, 
459,  460 
post-anesthetic,  195 
character  of  vomit,  195 
persistent,  195 
prevention  of,  137 
treatment  of,  195 

Water,  sterile,  43 
Wax,  Horsley  bone,  44'- 
Waxed  paper,  50 
Whale  oil,  44 

Whitman's   box    for   application   of 
plaster  cast,  341 
method  of  treatment  of  impacted 

fracture  of  neck  of  femur,  340 
plate  in  flat-foot,  194 
Wicking  drains,  146 
Wire,  iron,  sterilization  of,  56 

silver,  sterilization  of,  56 
Woelfler's  solution,  43 
Wool,  lambs',  48 
Wounds,  aseptic,  225 
drainage  in,  228 
healing  by  second  intention,  229 
in  infected  tissues,  238 
.    care  of,  225 

general  rules,  225 
skin  in  neighborhood  of,  245 
complications,  circulatory,  298 
result  of  antiseptics,  282 
of  pressure,  293 
disturbances    of,    result    of    anti- 
septics, 282 
of  pressure,  293 
dressing  of,  primary,  226 
healing  in  bony  defects,  358 
in  trephine  openings,  358 


Wounds,  healing  in  trephine  open- 
ings, per  primam,  normal  course, 
225 
hemorrhage  from,  diagnosis,  260 

treatment,  261 
indolent,  treatment  of,  240 
infection  of,  230 

as   cause  of  postoperative  rise 

of  temperature,   222 
Beck's  bismuth  paste  in,   254. 
See  also  Beckys  bismuth  paste. 
complications,  271 
early,  231 
immediate,  231 
in  loose  cellular  tissues,  238 
late,  233 

treatment,  283 
sinus  formation  in,  244 
spreading,  235 
vaccine  therapy  for,  246 
of  face,  after-treatment,  363 
of  pleura,  healing  process  in,  433 
of  rectum,  after-treatment,  495 
of  scalp,   erysipelas  complicating, 

352 
primary  oozing  from,  258 
redressing  of,  227 
resection,  after-treatment  of,  330 
retention  of  secretion  in,  by  block- 
age of  drain,  239 
revision  of  dressings  in,  225 
secondary  hemorrhage  from,  258 
diagnosis,  260 
late,  treatment  of,  262 
treatment,  261 
secretions  from,  retention  of,  234 

with  tension,  235 
thermocautery,  245 
Wry-neck,      operation     for,     after- 
treatment,  422 

Young's  method  of  perineal  prosta- 
tectomy, after-treatment  of,  520 

Zinc  oxid  gauze,  45 
plaster,  61 
powder,  39 
solution,  chlorid  of,  43 


SAUNDERS'  BOOKS 


on 


Nervous  and  Mental 
Diseases,  Children, 
Hygiene,  Nursing,  and 
Medical  Jurisprudence 

W.  B.  SAUNDERS   COMPANY 

WEST  WASHINGTON  SQUARE  PHILADELPHIA 

9,  HENRIETTA  STREET         COVENT  GARDEN,  LONDON 

THE  SUPERIORITY  OF  SAUNDERS'  TEXT=BOOK 

In  a  series  of  articles  entitled 

"WHAT  ARE  THE  BEST  MEDICAL  TEXT-BOOKS?" 

a  well  known  medical  journal  compiled  a  tabulation  of  the 
text-books  recommended  in  those  schools  which  are  members 
of  the  American  Association  of  Medical  Colleges.  The  text- 
books were  divided  into  twenty  (20)  subjects  and  under  each 
subject  was  given  a  list  of  the  various  books  with  the  number 
of  times  each  book  is  recommended.  Saunders'  books  head 
ten  (10)  of  the  twenty  (20)  subjects,  the  largest  number  head- 
ed by  any  other  publisher  being  three  (3).  In  other  words, 
Saunders'  books  lead  in  as  many  subjects  as  the  hooks  of  all  the  other 
publishers  combined. 

A  Complete  Catalogue  of  Our  Publications  will  be  Sent  upon  request 


SAUNDERS'    BOOKS    ON 


Church  and  Peterson's 
Nervous  and  Mental  Diseases 


Nervous  and  Mental  Diseases.  By  Archibald  Church,  M.  D., 
Professor  of  Nervous  and  Mental  Diseases  and  Medical  Jurisprudence, 
Northwestern  University  Medical  School,  Chicago ;  and  Frederick 
Peterson,  M.D.,  President  New  York  State  Commission  on  Lunacy: 
Professor  of  Psychiatry  at  the  College  of  Physicians  and  Surgeons, 
N.  Y.  Handsome  octavo,  934  pages;  341  illustrations.  Cloth,  ;g5.0G 
net ;  Half  Morocco,  ^6.50  net. 

THE  NEW  (7th)  EDITION 

For  this  new  seventh  edition  the  entire  work  has  been  most  thoroughly  re- 
vised. To  show  with  what  thoroughness  the  authors  have  revised  their  work,  we 
point  out  that  in  the  nervous  section  alone  over  one  hundred  and  fifty  interpola- 
tions have  been  made,  and,  in  addition,  well  over  three  hundred  minor  correc- 
tions. The  chapters  on  ^leningitis,  xA-phasia,  Poliomyelitis,  Pellagra,  and  Pituitary 
Diseases  have  been  practically  rewritten.  A  chapter  on  Oppenheim's  Congenital 
Amyatonia  has  been  introduced.  The  section  on  Mental  Diseases  has  been 
wholly  rearranged  to  conform  to  the  latest  classification,  some  obsolete  matter 
struck  out,  and  much  new  matter  added.  A  number  of  chapters  have  been  re- 
written. This  seventh  edition  embodies  every  substantial  advance  in  the  domains 
of  nervous  and  mental  diseases. 


OPINIONS  OF  THE    MEDICAL   PRESS 


American  Journal  of  the  Medical  Sciences 

"  This  edition  has  been  revised,  new  illustrations  added,  and  some  new  matter,  and  reallj 
is  two  books.  .  .  .  The  descriptions  of  disease  are  clear,  directions  as  to  treatment  definite, 
and  disputed  matters  and  theories  are  omitted.     Altogether  it  is  a  most  useful  text-book." 

Journal  of  Nervous  eoid  Mental  Diseases 

"The  best  text-book  exposition  of  this  subject  of  our  day  for  the  busy  practitioner.  .  .  . 
The  chapter  on  idiocy  and  imbecility  is  undoubtedly  the  best  that  has  been  given  us  in  any 
work  of  recent  date  upon  mental  diseases.  The  photographic  illustrations  of  this  part  of  Dr. 
Peterson's  work  leave  nothing  to  be  desired." 

New  York  Medical  Journal 

"To  be  clear,  brief,  and  thorough,  and  at  the  same  time  authoritative,  are  merits  that 
ensure  popularity.  The  medical  student  and  practitioner  will  find  in  this  volume  a  ready  and 
reliable  resource." 


MENTAL    DISEASES  AND   HYGIENE. 


Brill's  Psychanalysis 

THE   PRACTICAL  APPLICATION   OF  ALL  FREUD'S  THEORIES 

Psychanalysis  :  Its  Theories  and  Practical  Application,  By  A.  A. 
Brill,  Ph.  B.,  M.  D.,  Clinical  Assistant  in  Psychiatry  and  Neurology 
at  Columbia  University  Medical  School.     Octavo  of  337  pages. 

Cloth,  ;^3.00  net. 
JUST  READY 

To  the  general  practitioner,  who  first  sees  these  ' '  borderline ' '  cases  (the 
neuroses  and  the  psychoses),  as  well  as  to  those  specially  interested  in  neurologic 
work,  Dr.  Brill's  work  will  prove  most  valuable.  Dr.  Brill  has  had  wide  clinical 
experience,  both  in  America  and  in  Europe.  The  results  of  this  experience  you 
get  in  this  book.  Here  you  get  the  practical  application  of  all  Freud's  theories — 
and  from  the  pen  of  a  man  thoroughly  competent  to  write. 

Unlike  other  forms  of  psychotherapy,  psychanalysis  deals  with  the  neuroses 
as  entities.  It  does  not  treat  them  as  symptoms,  as  do  hypnotism,  suggestion, 
and  persuasion.  Such  treatment  is  similar  to  treating  the  cough  or  fever  regard- 
less of  the  causal  disease.  Psychanalysis  concerns  itself  with  the  individual  as  a 
personality.  It  enters  into  the  deepest  recesses  of  the  mind.  It  gives  you  a  real 
insight  into  the  neuroses  and  the  psychoses.  It  is  for  this  reason  that  the  results 
of  psychanalysis  are  most  effective.      Dr.  Brill  gives  you  the  exact  technic. 

Bergey*s  Hygiene 

The  Principles  of  Hygiene:  A  Practical  Manual  for  Students, 
Physicians,  and  Health  Officers.  By  D.  H.  Bergey,  A.  M.,  M.  D., 
Assistant  Professor  of  Bacteriology  in  the  University  of  Pennsylvania. 
Octavo  volume  of  555  pages,  illustrated.     Cloth,  ^3.00  net. 

THE  NEW  (4th)  EDITION 

This  book  is  intended  to  meet  the  needs  of  students  of  medicine  in  the 
acquirement  of  a  knowledge  of  those  principles  upon  which  modern  hygienic 
practises  are  based,  and  to  aid  physicians  and  health  officers  in  familiarizing 
themselves  with  the  advances  made  in  hygiene  and  sanitation  in  recent  years. 
This  new  third  edition  has  been  very  carefully  revised,  and  much  new  matter 
added,  so  as  to  include  the  most  recent  advancements. 

Buffalo  Medical  Journal 

"  It  will  be  found  of  value  to  the  practitioner  of  medicine  and  the  practical  sanitarian  ;  and 
students  of  architecture,  who  need  to  consider  problems  of  heating,  lighting,  ventilation,  vyrater 
supply,  and  sewage  disposal,  may  consult  it  with  profit." 


SAUNDERS'   BOOKS    ON 


The  New  "Dorlzknd" 

New  (6th)  Edition,  Entirely  Reset 

The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  Veterinary  Science,  Nursing,  and  kindred 
branches  ;  with  over  lOO  new  and  elaborate  tables  and  many  hand- 
some illustrations.  By  W.  A.  Newman  Borland,  M.  D.  Large 
octavo,  986  pages,  bound  in  full  flexible  leather,  ^4.50  net;  with  thumb 
index,  ^5.00  net. 

Borland's  Dictionar}-  defines  hundreds  of  the  newest  terms  not  defined  in  any 
other  dictionary — bar  none.  It  gives  the  capitahzation  and  pronunciation  of  all 
words.  It  makes  a  feature  of  the  derivation  or  etj'mology  of  the  words.  In 
"  Borland"  every  word  has  a  separate  paragraph,  thus  making  it  easy  to  find  a 
word  quickly.  The  tables  of  arteries,  muscles,  nerves,  veins,  etc.,  are  of  the 
greatest  help  in  assembling  anatomic  facts.  In  "Borland"  every  word  is  given 
its  definition — a  definition  that  defines  in  the  fewest  p'ossible  words. 

Howard  A.  Kelly,  M.  D.,  Johns  Hopkins  University,  Baltimore. 

"  Dr.  Dorland's  dictionary  is  admirable.     It  is  so  well  gotten  up  and  of  such  convenient 
size.     No  errors  have  been  found  in  my  use  of  it." 


Goodnow's  First-Year  Nursing  just  Ready 

First=Year  Nursing.  By  Mixxie  Goodxow,  R.  N.,  formerly  Superintendent  of  the 
Women's  Hospital,  Denver.      i2mo  of  328  pages,  illustrated.  Cloth,  $1.50  net. 

Miss  Goodnow's  work  deals  entirely  with  the  practical  side  of  first-year  nursing  work.  It 
is  the  application  of  text-book  knowledge.  It  tells  the  nurse  how  to  do  those  things  she  is 
called  upon  to  do  in  her  first  year  in  the  training  school — the  actual  ward  work. 

Roberts*  Bacteriology  and  Pathology  for  Nurses       Reidy 

Bacteriology  and  Pathology  for  Nurses.     By  Jay  G.  Roberts,  Ph.  G.,  M.  D., 

Oskaloosa,  Iowa.      i2rao  of  206  pages,  illustrated.  Cloth,  $1.25  net. 

This  new  work  is  practical  in  the  strictest  sense.  Written  specially  for  nurses,  it  confines 
itself  to  information  that  the  nurse  should  know.  All  unessential  matter  is  excluded.  The 
Style  is  concise  and  to  the  point,  yet  clear  and  plain.     The  text  is  illustrated  throughout. 


DISEASES   OF   CHILDREN. 


KerrV  Diagnostics  qf 
Diseases  qf  Children 

Diagnostics  of  the  Diseases  of  Children.  By  LeGrand  Kerr, 
M.  D.,  Professor  of  Diseases  of  Children,  Brooklyn  Postgraduate  Med- 
ical School,  Brooklyn.  Octavo  of  542  pages,  fully  illustrated.  Cloth, 
;^5.oo  net;  Half  Morocco,  $6.'^o  net. 

FOR  THE   PRACTITIONER 

Dr.  Kerr' s  work  differs  from  all  others  on  the  diagnosis  of  diseases  of  children 
in  that  the  objective  symptoms  are  particularly  emphasized.  The  constant  aim 
throughout  has  been  to  render  a  correct  diagnosis  as  early  in  the  course  of  the 
disease  as  possible,  and  for  this  reason  differential  diagnosis  is  presented  from 
the  very  earliest  symptoms.  The  many  original  illustrations  will  be  found 
helpful. 

New  York  State  Journal  of  Medicine 

"  The  illustrations  are  excellent  and  numerous.  It  will  meet  the  needs  of  the  great  mass 
of  physicians  who  treat  the  diseases  of  infancy  and  childhood." 

Kerley's  Treatment  qf 
Diseases  qf  Children 

Treatment  of  the  Diseases  of  Children.  By  Charles  Gilmore 
Kerley,  M.  D.,  Professor  of  Diseases  of  Children,  New  York  Polyclinic 
School  and  Hospital.  Octavo  of  628  pages,  illustrated.  Cloth,  ^5.00 
net;   Half  Morocco,  ^6.50  net. 

THE   NEW   (2d)    EDITION 

This  work  has  been  prepared  for  the  physician  engaged  in  general  practice. 
The  author  presents  all  the  modern  methods  of  management  and  treatment  in 
greater  detail  thajt  any  other  work  on  the  subject  heretofore  published.  The 
methods  suggested  are  the  results  of  actual  personal  experience,  extending  over  a 
number  of  years  of  hospital  and  private  practice.  There  is  an  excellent  illus- 
trated chapter  on  Gymnastic  Therapeutics. 

The  British  Medical  Journal 

"  Dr.  Kerley's  book  is  one  of  the  best  on  the  subject  that  has  come  under  our  notice.  All 
through  it  shows  evidence  of  ripe  experience  and  sound  judgment." 


SAUNDERS'  BOOKS  ON 


Sanders*  Nursing 

Modern  Methods  in  Nursing.  By  Georgiana  J.  Sanders,  formerly 
Superintendent  of  Nurses  at  the  Massachusetts  General  Hospital.  1 2mo 
of  88i  pages,  with  227  illustrations.     Cloth,  $2.50  net. 

THE  BEST  YET 

Miss  Sanders'  book  gives  only  moderti  methods.  Then  it  gives  the  details  of 
nursing  operation  cases,  both  in  the  hospital  and  in  the  home.  The  thorough  way 
in  which  ward  work  is  taken  up  makes  her  book  indispensable  for  teaching  pur- 
poses. In  giving  directions  for  mustard  baths,  poultices,  etc.,  the  quantities  zxg. 
given  exactly.     This  is  an  important  point  often  overlooked. 


Stoney's  Nursing 

Practical  Points  in  Nursing.  By  Emily  A.  M.  Stoney,  i2moof 
495  P^gss,  illustrated.     Cloth,  3 1.75  net. 

THE  NEW  (4th)  EDITION 

In  this  volume  the  author  explains  the  entire  range  of  private  nursmg  as  dis- 
tinguished from  hospital  nursing,  and  the  nurse  is  instructed  how  best  to  meet  the 
various  emergencies  of  medical  and  surgical  cases  when  distant  from  medical  or 
surgical  aid  or  when  thrown  on  her  own  resources.  An  especially  valuable  feature 
will  be  found  in  the  directions  how  to  improvise  everything  ordinarily  needed  in  the 
sick-room. 


Stoney *s  Technic  for  Nurses 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  Emily  A.  M. 
Stoney,  formerly  Superintendent  at  Carney  Hospital,  South  Boston. 
Revised  by  Frederic  R.  Griffith,  M.  D.,  Surgeon,  of  New  York. 
l2mo,  311  pages,  illustrated.      Cloth,  ^1.50  net. 

THE     NEW     f3d)     EDITION 
Traiined  Nurse  and  Hospital  Review 

"  These  subjects  are  treated  most  accurately  and  up  to  date,  without  the  superfluous  reading 
which  is  so  often  employed.  .  .  .  Nurses  wiU  find  this  book  of  the  greatest  value  both  during 
tneir  hospital  course  and  in  private  practice." 


NURSING. 


Nursing  in  Diseases  of  the 
Eye,  Ear,  Nose,  and  Throat 

Nursing  in  Diseases  of  tlie  Eye,  Ear,  Nose,  and  Throat.     By  the 

Committee  on  Nurses  of  the  Manhattan  Eye,  Ear,  and  Throat  Hospitah 
J.  Edward  Giles,  M.  D.,  Surgeon  in  the  Eye  Department ;  Arthur  B. 
Duel,  M.  D.  (Chairman),  Surgeon  in  the  Ear  Department ;  Harmon 
Smith,  M.  D.,  Surgeon  in  the  Throat  Department.  Assisted  by  John 
R.  Shannon,  M.  D.,  Assistant  Surgeon  in  the  Eye  Department ;  and 
John  R.  Page,  M.  D.,  Assistant  Surgeon  in  the  Ear  Department.  With 
chapters  by  Herbert  B.  Wilcox,  M.  D.,  A^ttending  Physician  to  the 
Hospital ;  and  Miss  Eugenia  D.  Ayers,  Superintendent  of  Nurses. 
l2mo  of  260  pages,  illustrated.  Cloth,  ;^i.50  net. 

A  VALUABLE  BOOK 

This  is  a  practical  book,  prepared  by  surgeons  who,  from  their  experience  in 
the  operating  amphitheater  and  at  the  bedside,  have  reahzed  the  shortcomings  of 
present  nursing  books  in  regard  to  eye,  ear,  nose,  and  throat  nursing.  The  scope 
of  the  work  has  been  hmited  to  what  an  inteUigent  nurse  should  know,  and  the 
style  throughout  is  simple,  plain,  and  definite. 

New  York  Medical  Journal 

"  Every  side  of  the  question  has  been  fully  taken  into  consideration." 

Stoney*s 
Materia  Medica  for  Nurses 


Practical  Materia  Medica  for  Nurses,  with  an  Appendix  containing 
Poisons  and  their  Antidotes,  with  Poison-Emergencies  ;  Mineral  Waters  ; 
Weights  and  Measures ;  Dose-List,  and  a  Glossary  of  the  Terms  used 
in  Materia  Medica  and  Therapeutics.  By  Emily  A.  M.  Stoney,  for- 
merly of  the  Carney  Hospital,  South  Boston.  i2mo  of  300  pages, 
Cloth,  $i.$o  net. 

THE    NEW  (3d)   EDITION 

In  making  the  revision  for  this  new  third  edition,  all  the  newer  drugs  have 
been  introduced  and  fully  discussed.  The  consideration  of  the  drugs  includes 
their  sources  and  composition,  thei-r  various  preparations,  physiologic  actions, 
directions  for  administering,  and  the  symptoms  and  treatment  of  poisoning. 

Journal  of  the  American  Medical  Association 

"  So  far  as  we  can  see,  it  contains  everything  that  a  nurse  ought  to  know  in  regard  to  drugs. 
As  a  reference-book  for  nurses  it  will  without  question  be  very  useful," 


SAUNDERS'  BOOKS  ON 


Hoxie  and  Laptad*s  Medicine  for  Nurses     j^^^  (2df  Edition 

Medicine  for  Nurses  and  Housemothers.  By  George  Howard  Hoxie, 
M.  D.,  Physician  to  the  German  Hospital,  Kansas  City,  Mo.;  and  Pearl  L. 
Laptad,  formerly  Principal  of  the  Training  School  for  Nurses,  University  of 
Kansas.      i2moof  351  pages,  illustrated.  Cloth,  Si. 50  net. 

This  work  is  truly  a  practice  of  medicine  for  the  nurse,  enabling  her  to  recognize  any 
signs  and  changes  that  may  occur  between  visits  of  the  physician,  and,  if  necessary,  to 
combat  them  until  the  physician's  arrival.  This  information  the  author  presents  in  a  way 
most  acceptable,  particularly  emphasizing  the  nurse's  part. 

Trained  Nurse  and  Hospital  Review 

"  This  book  has  our  unqualified  approval." 

McCombs*  Diseases  of  Children  for  Nurses  n^^  (2d)  Edition 

Diseases  of  Children  for  Nurses.  By  Robert  S.  McCombs,  M.  D., 
Instructor  of  Nurses  at  the  Children's  Hospital  of  Philadelphia.  i2mo  of 
470  pages,  illustrated.      Cloth,  $2.00  net. 

Dr.  McCombs"  experience  in  lecturing  to  nurses  has  enabled  him  to  e.mTp\\as\z&  Just  those 
foints  that  nurses  most  Heed  to  know.  The  nursing  side  has  been  written  by  head  nurses, 
especially  praiseworthy  being  the  work  of  Miss  Jennie  Manly. 

National  Hospital   Record 

"  We  have  needed  a  good  work  on  children's  diseases  adapted  for  nurses'  use,  and  this 
volume  admirably  fills  the  want." 

Wilson's    Obstetric   Nursing  The  New  (2d)  Edition 

A  Reference  Hand=Book  of  Obstetric  Nursing.  By  W.  Reynolds 
WiLsox,  ]\I.  D.,  Visiting  Physician  to  the  Philadelphia  Lying-in  Charity. 
32mo  of  256  pages,  illustrated.     Flexible  leather,  $1.25  net. 

Dr.  Wilson's  work  discusses  the  subject  of  obstetrics  entirely  from  the  nurse's  point  of 
view,  presenting  in  detail  everything  connected  with  pregnancy  and  labor  and  their  man- 
agement.    The  text  is  copiously  illustrated. 

American  Journal  of  Obstetrics 

"  Everv  page  emphasizes  the  nurse's  relation  to  the  case." 

Friihwald  and  Westcott  on  Children 

Diseases  of  Children.  A  Practical  Reference  Book  for  Students  and 
Practitioners.  By  Professor  Dr.  Ferdinand  Fruhwald,  of  Menna. 
Edited,  with  additions,  by  Tho.aipson  S.  Westcott,  :M=  D.,  University  of 
Pennsylvania.     Octavo,  533  pages,  176  illustrations.     Cloth,  $4. 50  net. 

Boyd's  State  Regfistration  for  Nurses 

state  Registration  for  Nurses.  By  Louie  Croft  Boyd,  R.  N.  ,  Graduate 
Colorado  Training-school  for  Nurses.     Octavo  of  42  pages.  50  cents  net. 


NURSING. 


Aikens*  Primary  Studies  for  Nurses  ^ew  (2d)  Edition 

Primary  Studies  for  Nurses  :  A  Text-Book  for  First-year  Pupil 
Nurses.  By  Charlotte  A.  Aikens,  formerly  Director  of  Sibley  Memorial 
Hospital,  Washington,  D.  C.     i2mo  of  437  pages,  illus.    Cloth,  ^1.75  net. 

This  work  brings  together  in  concise  form  well-rounded  courses  of  lessons 
in  all  subjects  which,  with  practical  nursing  technic,  constitute  the  primary 
studies  in  a  nursing  course. 

Trained  Nurse  and  Hospital  Review 

"It  is  safe  to  say  that  any  pupil  who  has  mastered  even  the  major  portion  of  this  work 
would  be  one  of  the  best  prepared  first-year  pupils  that  ever  stood  for  examination." 

Aikens'  Clinical  Studies  for  Nurses  ^ew  (2d)  Edition 

Clinical  Studies  for  Nurses.  By  Charlotte  A.  Aikens,  formerly 
Director  of  Sibley  Memorial  Hospital,  Washington,  D.  C.  i2mo  of 
569  pages,  illustrated.     Cloth,  $2.00  net. 

This  new  work  is  written  along  the  same  lines  as  Miss  Aikens'  former 
work  on  "  Primary  Studies,"  to  which  it  is  a  companion  volume.  It  takes 
up  all  subjects  taught  during  the  second  and  third  years  and  takes  them 
up  in  a  concise,  forceful  way. 

Dietetic  and  Hygienic  Geusette 

"  There  is  a  large  amount  of  practical  information  in  this  book  which  the  experienced 
nurse,  as  well  as  the  undergraduate,  will  consult  with  profit.  The  illustrations  are 
numerous  and  well  selected." 

Aikens'  Training'-School  Methods 

Hospital  Training-School  Methods  and  the  Head  Nurse.  By 
Charlotte  A.  Aikens,  formerly  Director  of  Sibley  Memorial  Hospital, 
Washington,  D.  C.      i2mo  of  267  pages.     Cloth,  $1.50  net. 

Treaned  Nurse  and  Hospital  Review 

"  There  is  not  a  chapter  in  the  book  that  does  not  contain  valuable  suggestions." 

Aikens'  Hospital  Management  Extremely  Practical 

Hospital  Management.  By  Charlotte  A.  Aikens,  formerly  Direc- 
tor of  Sibley  Memorial  Hospital,  Washington,  D.  C.  i2mo  of  488 
pages,  illustrated.  Cloth,  ^3.00  net. 

The  Medical  Record 

"  Tells  in  concise  form  exactly  what  a  hospital  should  do  and  how  it  should  be  run, 
from  the  scrubwoman  up  to  its  financing.  A  valuable  addition  to  our  literature  on  this 
subject." 


SAUNDERS'  BOOKS  ON 


Bolduan  and  Grund's  Bacteriology  for  Nurses  Ready 

Applied  Bacteriology  for  Nurses.  By  Charles  F.  Bolduan, 
M.  D.,  Assistant  to  the  General  Medical  Officer;  and  Marie  Grund, 
M.  D.,  Bacteriologist,  Research  Laboratory,  Department  of  Health, 
New  York  City.      12 mo  of  155  pages,  illustrated.  Cloth,  ^1.25  net. 

We  were  fortunate  in  getting  these  practical  physicians  to  write  tliis  work.  It  gives  par- 
ticular emphasis  to  the  immediate  application  of  bacteriology  to  nursing,  only  the  really 
practical  being  included.  A  study  of  all  the  modes  of  infection  transmission  is  presented. 
At  the  end  of  each  chapter  are  suggestions  for  practical  demonstration. 

Register's  Fever  Nursing 

A  Text-Book  on  Practical  Fever  Nursing.  By  Edward  C. 
PvEGiSTER,  M.  D.,  Professor  of  the  Practice  of  Medicine  in  the  North 
Carolina  Medical  College.      i2mo  of  352  pages.     Cloth,  $2.50  net. 

Hecker,  Trumpp,  and  Abt  on  Children 

Atlas  and  Epitome  of  Diseases  of  Children,  By  Dr.  R.  Hecker 
and  Dr.  J.  TrUxMPP,  of  Munich.  Edited,  with  additions,  by  Isaac  A. 
Abt,  M.D.,  Assistant  Professor  of  Diseases  of  Children,  Rush  Medical 
College,  Chicago.  With  48  colored  plates,  144  text-cuts,  and  453  pages 
of  text.     Cloth,  ^5.00  net. 

The  many  excellent  lithographic  plates  represent  cases  seen  in  the  authors'  clinics,  and 
have  been  selected  with  great  care,  keeping  constantly  in  mind  the  practical  needs  of  the 
general  practitioner.  These  beautiful  pictures  are  so  true  to  nature  that  their  study  is 
equivalent  to  actual  clinical  observation.  The  editor,  Dr.  Isaac  A.  Abt,  has  added  all  new 
methods  of  treatment. 

Lewis*   Anatomy   and    Physiology  The  New  (2d)  Edition 

Anatomy  and  Physiology  for  Nurses.  By  LeRoy  Lewis,  M.  D., 
Formerly  Surgeon  to  and  Lecturer  on  Anatomy  and  Physiology  for 
Nurses  at  the  Lewis  Hospital,  Bay  City,  ]Michigan.  i2mo  of  344  pages, 
with  161  illustrations.      Cloth,  $1.75  net. 

A  demand  for  such  a  work  as  this,  treating  the  subjects  fj-o^ti  the  ntirses'  point  of  view, 
has  long  existed.  Dr.  Lewis  has  based  the  plan  and  scope  of  this  work  on  the  methods 
employed  by  him  in  teaching  these  branches,  making  the  text  unusually  simple  and  clear. 

The  Nurses  Journal  of  the  Pacific  Coast 

"  It  is  not  in  any  sense  rudimentary,  but  comprehensive  in  its  treatment  of  the  subjects 
in  hand.  The  application  of  the  knowledge  of  anatomy  in  the  care  of  the  patient  is 
emphasized." 

Friedenwald  and  Ruhrah*s  Dietetics  New  (2d)  Edition 

Dietetics  for  Nurses.  By  Julius  Friedenwald,  M.  D.,  Professor 
of  Diseases  of  the  Stomach,  and  John  Ruhrah,  M.  D.,  Professor  of 
Diseases  of  Children,  College  of  Physicians  and  Surgeons,  Baltimore. 
121110  volume  of  395  pages.     Cloth,  ^1.50  net. 

This  work  has  been  prepared  to  meet  the  needs  of  the  nurse,  both  in  the  training 
school  and  after  graduation.  It  aims  to  give  the  essentials  of  dietetics,  considering  briefly 
the  physiology  of  digestion  and  the  various  classes  of  foods  and  the  part  they  play  in 
nutrition. 

American  Journal  of  Nursing 

"  It  is  exactly  the  book  for  which  nurses  and  others  have  long  and  vainly  sought.  A 
simple  manual  of  dietetics,  which  does  not  turn  into  a  cook-book  at  the  end  of  the  first 
or  second  chapter. 


NURSING  AND  CHILDREN. 


II 


Paul's  Fever  Nursing  New  (2d)  Edition 

Nursing  in  the  Acute  Infectious  Fevers.  By  George  P.  Paul, 
M.  D.,  formerly  Assistant  Visiting  Physician  to  the  Samaritan  Hospital, 
Troy,  N.  Y.     i2mo  of  246  pages.     Cloth,  ^i.oo  net. 

Dr.  Paul  has  taken  great  pains  in  the  presentation  of  the  care  and  management  of  each 
fever.  The  book  treats  of  fevers  in  general,  then  each  fever  is  discussed  individually,  and 
the  latter  part  of  the  book  deals  vifith  practical  procedures  and  valuable  information. 

The  London  Lancet 

"  The  book  is  an  excellent  one  and  will  be  of  value  to  those  for  whom  it  is  intended. 
It  is  well  arranged,  the  text  is  clear  and  full,  and  the  illustrations  are  good." 

Paul's  Materia  Medica  for  Nurses  New  (2d)  Edition 

Materia  Medica  for  Nurses.  By  George  P.  Paul,  M.  D.,  formerly 
Assistant  Visiting  Physician  to  the  Samaritan  Hospital,  Troy.  1 2mo  oi 
282  pages.     Cloth,  ^1.50  net. 

Dr.  Paul  arranges  the  physiologic  actions  of  the  drugs  according  to  the  action  of  the 
drug  and  not  the  organ  acted  upon.  An  important  section  is  that  on  pretoxic  signs, 
giving  the  warnings  of  the  full  action  or  the  beginning  toxic  effects  of  the  drug,  which, 
if  heeded,  may  prevent  many  cases  of  drug  poisoning. 

The  Medical  Record,  New  York 

"This  volume  will  be  of  real  help  to  nurses;  the  material  is  well  selected  and  well 
arranged,  and  the  book  is  as  readable  as  it  is  useful." 

Pyle's  Personal  Hygiene  The  New  (5th)  Edition 

A  Manual  of  Personal  Hygiene  :  Proper  Living  upon  a  Physiologic 
Basis.  By  Eminent  Specialists.  Edited  by  Walter  L.  Pyle,  A.M., 
M.D.,  Assistant  Surgeon  to  Wills  Eye  Hospital,  Philadelphia.  Octavo 
volume  of  515  pages,  fully  illustrated.     Cloth,  ^1.50  net. 

The  book  has  been  thoroughly  revised  for  this  new  edition,  and  a  new  chapter  on 
Food  Adulteration  by  Dr.  Harvey  W.    Wiley  added.      There  are  important  chapters 
on   Domestic   Hygiene  and  Home  Gymnastics,   Hydrotherapy,    Mechanotherapy,  and 
First  Aid  Measures. 
Boston  Medical  and  Surgical  Journal 

"  The  work  has  been  excellently  done,  there  is  no  undue  repetition,  and  the  writers 
have  succeeded  unusually  well  in  presenting  facts  of  practical  significance  based  on  sound 
knowledge." 

Galbraith's  Four  Epochs  of  Woman's  Life     second  Edition 

The   Four   Epochs  of  Woman's   Life.     By  Anna  M.   Galbraith, 
M.D.      With  an  Introductory  Note  by  John  H.  Musser,  M.D.,  Univer- 
sity of  Pennsylvania.      i2mo  of  247  pages.      Cloth,  ^1.50  net. 
Birmingham  Medical  Review 

"  We  do  not  as  a  rule  care  for  medical  books  written  for  the  instruction  of  the  public; 
but  we  must  admit  that  the  advice  in  Dr.  Galbraith's  work  is  in  the  main  wise  and  whole- 
some." 

Spratlin|(  on  Epilepsy 

Epilepsy  and  Its  Treatment.  By  William  P.  Spratling,  M.  D.,  Pro- 
fessor of  Physiology  and  Nervous  Diseases,  College  of  Physicians  and  Sur- 
geons, Baltimore.     Octavo  of  522  pages,  fully  illustrated.      Cloth,  $4.00  net. 

The  Lancet,  London 

"  Dr.  Spratling's  work  is  written  throughout  in  a  clear  and  readable  style.  .  .  .  The 
work  is  a  mine  of  information  on  the  whole  subject  of  epilepsy  and  its  treatment." 


SAUNDERS'    BOOKS    OIV 


Macfarlane's  Gynecology  for  Nurses  New  (2d)  Edition 

A  Reference  Hand-Book  of  Gynecology  for  Nurses.  By  Cath- 
arine IMacfarlane,  M.  D.,  Gynecologist  to  the  Woman's  Hospital  of 
Philadelphia.  i6mo  of  150  pages,  with  70  illustrations.  Flexible 
leather,  $1.25  net. 

A.  M.  Seabrook,   M.  D.,    Woman  s  Medical  College  of  Philadelphia. 

"  It  is  a  most   admirable  little  book,  covering  in  a  concise  but   attractive  way  the   subject  from 
the  nurse's  standpoint." 

Galbraith*s  Personal  Hygiene  for  Women 

Personal  Hygiene  and  Physical  Training  for  Women.  By 
Anna  M.  Galbraith,  M.D.,  Fellow  New  York  Academy  of  Medicine, 
i2mo  of  371  pages,  with  original  illustrations.  Cloth,  ^2.00  net. 

Dietetic  and  Hygienic  Ga^zette 

"  It  contains  just  the  sort  of  iniormation  which  is  very  greatly  needed  by  the  weaker  sex.      Its  illus- 
trations are  excellent." 

De  Lee's   Obstetrics   for   Nurses  New  (4th)  Edition 

Obstetrics  for  Nurses.     By  Joseph  B.  DeLee,  M.  D.,  Professor  of 
•    Obstetrics  in  the  North\vestern  UniYersity  Medical  School.      i2mo  yoI- 
ume  of  508  pages,  fully  illustrated.     Cloth,  $2.50  net. 

J.  Clifton    Edgar,  M.  D., 

P7-i-'/essor  of  Obstetrics  and  Clinical  Midiuifery ,  Cornell  Medical  School,  N.  Y. 

"  It  is  far-and-away  the  best  that  has  come  to  my  notice,  and  I  shall  take  great  pleasure  in  recom- 
mending it  to  my  nurses  and  students  as  well." 

Davis*   Obstetric   Nursing  New  (4i7*EdSon 

Obstetric  and  Gynecologic  Nursing.  By  Edward  P.  Davis,  A.  M., 
M.  D.,  Professor  of  Obstetrics,  Jefferson  ]\Iedical  College  and  Philadel- 
phia Polyclinic.      i2mo  of  480  pages,  illustrated.     Buckram,  ^1.75  net. 

The  Lancet,  London 

"  Not  only  nurses,  but  even  newly  qualified  medical  men,  would  learn  a  great  deal  by  a  perusal  of 
this  book.      Itis  written  in  a  clear  and  pleasant  style,  and  is  a  work  we  can  recommend." 

Beck's   Hand-Book  for  Nurses  New  (2di  Edition 

A  Reference  Hand-Book  for  Nurses.  By  Amanda  K.  Beck,  of 
Chicago,  111.     32mo  of  200  pages.     Flexible  leather,  51-25  net. 

Aikens'  Home  Nurse's  Hand-Book  just  Ready 

Home  Nursf.'s  Hand-Book.  By  Charlotte  A.  Aikens.  i2moof  276 
pages,  illustrated.  Cloth,  Si. 50  net. 

The  point  about  this  work  is  this  :  It  tells  you  and  shows  you  just  how  to  do  those 
little  but  imporant  things  often  omitted  from  other  nursine  bool<s.  "Home  Treat- 
ments" and  "Points  to  be  Remembered" — terse,  crisn  reminders — stand  out  as  par- 
ticularly practical.     Just  the  book  for  those  who  have  the  home-care  of  the  sick. 


CHILDREN  AND   HYGIENE.  13 

Griffith's  Care  of  the  Baby 

The  Care  of  the  Baby.  By  J.  P.  Crozer  Griffith,  M.  D.,  Clinical 
Professor  of  Diseases  of  Children,  University  of  Penn. ;  Physician  to  the 
Children's  Hospital,  Phila.    i2mo,  455  pp.  Illustrated.    Cloth,  $1.50  net. 

THE  NEW  (5th)  EDITION 

The  author  has  endeavored  to  furnish  a  rehable  guide  for  mothers.  He  has 
made  his  statements  plain  and  easily  understood,  so  that  the  volume  will  be  of 
service  to  mothers  and  nurses. 

New  York  Medical  Journal 

"We  are  confident  if  this  Itttle  work  could  find  its  Ka.j  into  the  hands  of  every  trained 
nurse  and  of  every  mother,  infant  mortality  would  be  lest.e«ied  by  at  least  fifty  per  cent." 


Grulee*s  Infant  Feeding 

Infant  Feeding.  By  Clifford  G.  Grulee,  M.  D.,  Assistant  Pro- 
fessor of  Pediatrics  at  Rush  Medical  College.  Octavo  of  295  pages,  illus- 
trated, including  8  in  colors.     Cloth,  $3.00  net. 

JUST  READY 

Dr.  Grulee  tells  you  how  to  feed  the  infant.  He  tells  you — and  shows  by  clear 
illustrations — the  tecJinic  of  giving  the  child  the  breast.  Then  artificial  feeding  is 
thoughtfully  presented,  including  a  number  of  simple  formulas.  The  colored  illus- 
trations showing  the  actual  shapes  and  appearances  of  stools  are  extremely 
valuable. 


Ruhrah's   Diseases   of    Children 

A  Manual  of  Diseases  of  Children.  By  John  Ruhrah,  M.  D., 
Professor  of  Diseases  of  Children,  College  of  Physicians  and  Surgeons, 
Baltimore.  i2mo  of  534  pages,  fully  illustrated.  Flexible  leather, 
$2.50  net. 

THE  NEW  (3d)  EDITION 

In  revising  this  work  for  the  second  edition  Dr.  Ruhrah  has  carefully  in- 
corporated all  the  latest  knowledge  on  the  subject.  All  the  important  facts  are 
given  concisely  and  explicitly,  the  therapeutics  of  infancy  and  childhood  being 
outlined  very  carefully  and  clearly.  There  are  also  directions  for  dosage  and 
prescribing,  and  many  useful  prescriptions  are  included. 

American  Journal  of  the  Medical  Sciences 

"Treatment  has  been  satisfactorily  covered,  being  quite  in  accord  with  the  best  teaching, 
yet  withal  broadly  general  and  free  from  stock  prescriptions." 


14  SAUNDERS'    BOOKS   ON 

Peterson  and  Haines* 
Leg(al  Medicine  £>  Toxicolog(y 


A  Text=Book  of  Legal  Medicine  and  Toxicology.  Edited  by 
Frederick  Peterson,  M.  D.,  Professor  of  Psychiatry  in  the  College 
of  Physicians  and  Surgeons,  New  York ;  and  Walter  S.  Haines, 
M.  D.,  Professor  of  Chemistry,  Pharmacy,  and  Toxicolog}^,  Rush 
Medical  College,  in  affiliation  with  the  University  of  Chicago.  Two 
imperial  octavo  volumes  of  about  750  pages  each,  fully  illustrated. 
Per  volume:  Cloth,  $5.00  net;  Sheep  or  Half  Morocco,  ;$6.5o  net 
Sold  by  Subscriptioji. 

IN  TWO   VOLUMES 

The  object  of  the  present  work  is  to  give  to  the  medical  and  legal  professions 
a  comprehensive  survey  of  forensic  medicine  and  toxicology^  in  moderate  compass. 
Under  "  Expert  Evidence"  not  only  is  advice  given  to  medical  experts,  but  sug- 
gestions are  also  made  to  attorneys  as  to  the  best  methods  of  obtaining  the  desired 
information  from  the  witness. 
Columbia  Law  Review 

"  For  practitioners  in  criminal  law  and  for  those  in  medicine  who  are  called  upon  to  give 
court  testimony  in  all  its  various  forms  ...  it  is  extremely  valuable." 


Fiske's  Human  Body 

structure  and  Functions  of  the  Body.  By  Annette  Fiske,  A.M., 
Graduate  of  the  Waltham  Training  School  for  Nurses.  i2mo  of  221 
pages,  illustrated.     Cloth,  $1.25  net. 

PRESENTED   IN  A   NEW  WAY 

The  way  in  which  this  book  presents  anatomy  and  physiology  is  a  departure 
from  the  usual  method — a  departure,  however,  of  a  ver}'  practical  kind.  Miss 
Fiske  has  woven  the  physiology  in  with  the  anatomy,  thus  making  her  work  a 
most  readable  one.  It  is  an  extrem^ely  practical  book — one  that  can  be  readily 
understood. 

Brower  and  Bannister's  Insanity 

Manual  of  Insanity.  By  Daniel  R.  Brower,  M.  D.,  Rush  Medical  College; 
and  Henry  M.  Bannister,  M.  D.,  Illinois  Eastern  Hospital  for  Insane.  Octavo  of 
426  pages,  illustrated.     Cloth,  $3.00  net. 


LEGAL   MEDICINE 


15 


Bohm  and  Painter's  Massage  just  Ready 

Massage.  By  Max  Bohm,  M.  D.,  of  Berlin,  Germany.  Edited,  with  an 
Introduction,  by  Charles  F.  Painter,  M,  D.,  Professor  of  Orthopedic  Sur- 
gery at  Tufts  College  Medical  School,  Boston.  Octavo  of  91  pages,  with  70 
practical  SS\.M?XxsX\on's,.  Cloth,  ^1.75  net. 

Draper's  Leg'al  Medicine 

A  Text=Book  of  Legal  Medicine.  By  Frank  Winthrop  Draper,  A.  M., 
M,  D.,  Late  Professor  of  Legal  Medicine  in  Harvard  LTniversity,  Boston. 
Octavo  of  573  pages,  illustrated.      Cloth,  $4.00  net ;  Half  Morocco,  $5.50  net. 

Chapman's  Medical  Jurisprudence  Third  Edition 

Medical  Jurisprudence,  Insanity,  and  Toxicology.  By  Henry  C. 
Chapman,  M.  D.,  late  Professor  of  Institutes  of  Medicine  and  Medical  Juris- 
prudence in  Jefferson  Medical  College,  Philadelphia.  i2mo  of  329  pages, 
illustrated.      Cloth,  $1.75  net. 

Golebiewski  and  Bailey's  Accident  Diseases 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents.      By   Dr.   Ed. 

Golebiewski,  of  BerHn.  Edited,  with  additions,  by  Pearce  Bailey,  M.  D., 
Consulting  Neurologist  to  St.  Luke's  Hospital,  New  York.  With  71  colored 
illustrations  on  40  plates,  143  text  illustrations,  and  549  pages  of  text.  Cloth, 
$4.00  net.      In  Saunders'  Hand-Atlas  Series. 

Hofmann  and  Peterson's  Le^al   Medicine      HandXirses 

Atlas  of  Legal  Medicine.  By  Dr.  E.  von  Hofmann,  of  Vienna. 
Edited  by  Frederick  Peterson,  M.  D.,  Professor  of  Psychiatry  in  the 
College  of  Physicians  and  Surgeons,  New  York.  With  120  colored  figures 
on  56  plates  and  193  half-tone  illustrations.      Cloth,  ^3.50  net. 

Jakob  and  Fisher's  Nervous  System  ^^Atfasei 

Atlas  and   Epitome  of  the  Nervous   System  and  its  Diseases.      By 

Professor  Dr.  Chr.  Jakob,  of  Erlangen.  Edited,  with  additions,  by  Ed- 
ward D.  Fisher,  M.  D.,  University  and  Bellevue  Hospital  Medical  College. 
With  83  plates  and  copious  text.      Cloth,  $3.50  net. 

Crothers'  Morphinism  and  Narcomania 

Morphinism  and  Narcomania.  By  T.  D.  Crothers,  M.  D.  i2mo  of 
351  pages.     Cloth,  $2.00  net. 

Abbott's  Transmissible  Diseases  second  Edition 

The  Hygiene  of  Transmissible  Diseases :  Their  Causes,  Modes  of  Dis- 
semination, and  Methods  of  Prevention.  By  A.  C.  Abbott,  M.  D.,  Pro- 
fessor of  Hygiene  and  Bacteriology,  University  of  Pennsylvania.  Octavo  of 
351  pages,  illustrated.     Cloth,  $2.50  net. 


l6  SAUiYDERS'   BOOKS  OiY  CHILDREN. 

American  Pocket  Dictionary  New  (7th^  f^k-^os 

American  Pocket  Medical  Dictionary.  Edited  by  W,  A.  New- 
man Borland,  M.  D.,  Editor  "American  Illustrated  Medical  Dic- 
tionary." Containing  the  pronunciation  and  definition  of  the  principal 
words  used  in  medicine  and  kindred  sciences,  with  64  extensive  tables. 
With  610  pages.  Flexible  leather,  with  gold  edges,  ^i.oo  net;  with 
patent  thumb  index,  $1.25  net. 

"  I  can  recommend  it  to  our  students  without  reserve." — J.  H.  HOLLAND,  M.  D.,  Dean 
ofthejefferson  Medical  College,  Philadelphia. 

Morrow's  Immediate  Care  of  Injured  ^^^^  (2d)  Edition 

Immediate  Care  of  the  Injured.  By  Albert  S.  Morrow,  AI.  D., 
Adjunct  Professor  of  Surgery  at  the  New  York  Polyclinic.  Octavo  of  360 
pages,  with  242  illustrations.      Cloth,  $2.50  net. 

Dr.  Morrow's  book  on  emergency  procedures  is  written  in  a  definite  and  decisive  style, 
the  reader  being  told  just  what  to  do  in  every  emergency.  It  is  a  practical  book  for  every 
day  use,  and  the  large  number  of  excellent  illustrations  can  not  but  make  the  treatment  to 
be  pursued  in  any  case  clear  and  intelligible.    Physicians  and  nurses  will  find  it  indispensible. 

Powell's    Diseases    of   Children  Third  Edition.  Revised 

Essentials  of  the  Diseases  of  Children.  By  William  M.  Powell, 
M.  D.  Revised  by  Alfred  Hand,  Jr.,  A.  B.,  M.  D.,  Dispensary 
Physician  and  Pathologist  to  the  Children's  Hospital,  Philadelphia. 
i2mo  volume  of  259  pages.  Cloth,  $1.00  net.  In  Saunders'' 
Question-  Compend  Series. 

Shaw  on  Nervous  Diseases  and  Insanity      Fourth  Edition 

Essentials  of  Nervous  Diseases  and  Insanity  :  Their  Symptoms 
and  Treatment.  A  Manual  for  Students  and  Practitioners.  By  the  late 
John  C.  Shaw,  M.  D.,  Clinical  Professor  of  Diseases  of  the  Mind  and 
Nervous  System,  Long  Island  College  Hospital,  New  York.  i2mo  of 
204  pages,  illustrated.  Cloth,  ^i.oo  net.  Ifi  Saunders'  Questiofi-Com- 
pend  Series. 

"  Clearly  and  intelligently  written ;  we  have  noted  few  inaccuracies  and  several  sug- 
gestive points.  Some  affections  unmentioned  in  many  of  the  large  text-books  are  noted." 
— Boston  Medical  and  Surgical  Jo7ir7ial. 

Starr's  Diets  for  Infants  and  Children 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.  By 
Louis  Starr,  M.  D.,  Consulting  Pediatrist  to  the  Maternity  Hospital, 
Philadelphia.  230  blanks  (pocket-book  size).  Bound  in  flexible  leather, 
^1.25  net. 

Grafstrom's    MechanO-Therapy  second  Revised  Edition 

A  Text-book  of  Mechano-therapy  (Massage  and  Medical  Gymnas- 
tics). By  Axel  Y.  Grafstrom,  B.  Sc,  INI.  D.,  Attending  Physician  to 
the  Gustavus  Adolphus  Orphange,  Jamestown,  Nev/  York.  i2mo,  200 
pages,  illustrated.     Cloth,  $1.25  net. 


I 


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